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RUSSELL  SAGE 
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SOCIAL  WORK  IN 
HOSPITALS 

A  CONTRIBUTION   TO 
PROGRESSIVE  MEDICINE 


BY 
IDA  M.  CANNON,  R.  N. 

HEAD  WORKER,    SOCIAL    SERVICE    DEPARTMENT 
MASSACHUSETTS    GENERAL    HOSPITAL 


NEW   YORK 

SURVEY   ASSOCIATES,    INC. 
MCMXIII 


Copyright,  1913,  by 
THE  RUSSELL  SAGE  FOUNDATION 


PRESS  OF  WM.  F.  FELL  CO. 
PHILADELPHIA 


To  DR.  RICHARD  C.  CABOT 
whose  insight,  constructive  imagination 
and  fearless  pioneer  spirit  have  been  the 
chief  factors  in  starting  and  bringing  to 
its  present  status  in  this  country,  organ- 
ized hospital  social  service. 


2GC664.2 


PREFACE 

IN  THE  winter  of  1912  I  had  the  interesting 
opportunity  of  visiting  most  of  the  hospital 
social  service  departments  in  this  country. 
At  that  time  I  was  impressed  by  the  variety  of 
types  of  organization,  by  the  diversities  in  the 
interpretations  of  the  hospital  social  worker's 
function,  and  by  the  great  need  for  more  ade- 
quately trained  workers.  In  every  department  the 
paid  workers  were  women.  It  was  interesting  to 
note,  however,  that  in  some  instances  men — es- 
pecially medical  students — were  being  drawn  into 
volunteer  service.  I  was  even  more  impressed 
with  the  widespread  interest  that  I  found  among 
physicians,  hospital  authorities,  and  lay  people, 
in  this  new  conception  of  the  hospital's  social  re- 
sponsibilities. If  hospital  authorities  and  physi- 
cians are  persuaded  that  social  work  is  needed  as 
part  of  thorough  treatment  of  the  sick,  surely  the 
workers,  in  spite  of  their  handicaps  in  training,  in 
spite  of  the  lack  of  standardization  in  their  case 
work  and  in  their  organization,  are  meeting,  never- 
theless, a  real  need.  Every  department  I  visited 
seemed  to  me  pervaded  by  a  genuine  spirit  of  ser- 
vice. Eagerness  for  information  concerning  all 
phases  of  the  hospital's  social  problems  was  also 


PREFACE 

notable  among  those  actually  engaged  in  the  work. 
This  very  general  desire  and  evident  need  for  ex- 
change of  experience  and  for  a  more  conscious  and 
consistent  effort  to  establish  standards,  has  made 
it  seem  worth  while  to  present  this  preliminary 
survey  of  the  present  status  of  hospital  social  work. 

Suggestions  have  come  to  me  from  workers  in 
various  existing  departments  and  from  an  inter- 
esting personal  experience.  To  make  acknowl- 
edgment to  all  who  are  responsible  for  material 
presented  in  this  book  would  be  impossible.  The 
material  has  come  to  me  in  some  instances  un- 
consciously, but  more  often  with  the  most  gen- 
erous spirit  of  helpfulness  from  hospital  social 
workers,  from  physicians  and  institution  execu- 
tives, and  also  from  many  other  friends  of  social 
service, — among  them  the  patients  themselves. 

I  am  indebted  to  my  sister,  Cornelia  James  Can- 
non, and  to  Miss  Elizabeth  V.  H.  Richards,  Head 
Worker  of  the  Social  Service  Department  of  the 
Boston  Dispensary,  with  whom  many  of  the  sub- 
jects in  this  little  book  have  been  discussed. 

Especially  am  I  under  obligation  to  Dr.  Richard 
C.  Cabot,  whose  stimulating  leadership  I  have  en- 
joyed for  six  years.  He  has  read  the  manuscript 
and  made  invaluable  suggestions.  I  am  indebted 
also  to  Miss  Mary  E.  Richmond,  without  whose 
stimulus  and  interest  the  book  would  not  have 
been  attempted. 


viii 


TABLE  OF  CONTENTS 

PAGE 

PREFACE vii 

LIST  OF  FORMS xi 

I.  Introductory i 

II.  The  Beginnings  of  Hospital  Social  Service     .       6 

III.  The  Hospital  Background      .       .       .       .18 

IV.  Medical-Social  Problems 33 

The  Tuberculous.   The  Convalescent.   Vic- 
tims of  Chronic  Diseases. 

V.  Medical-Social  Problems  (continued)    .        .     50 
The  Unmarried  Mother.     The  Syphilitic. 
The  Mentally  Unbalanced.     The  Neuras- 
thenic.   The  Suicidal.   TheFeeble-Minded. 
VI.  Medical-Social  Problems  (concluded)     .       .     80 
Relief.     Employment  for  the  Handicapped. 
Medical  Advice  to  Social  Agencies. 

VII.  Basis  of  Treatment 106 

VIII.  Working  Together 124 

IX.  Records 142 

X.  Organization 159 

XI.  Workers 180 

XII.  The  Future  of  Hospital  Social  Service.        .  200 

APPENDIX.     Forms  and  Facsimiles  (see  p.  xi)       .219 
INDEX 241 


LIST  OF  FORMS 

PAGE 

Diagram  showing  the  relation  of  medical  and  social  con- 
ditions as  found  by  the  hospital  social  worker  .  .  22 1 

Form  used  by  agencies  referring  patients  to  dispensaries 
for  report  of  physical  conditions  through  a  social 
service  department.  Massachusetts  General  Hos- 
pital   222 

Same.     Boston  Dispensary 223 

Analysis  of  the  hospital  expense  involved  in  free  treat- 
ment of  a  family  of  eleven  coming  to  the  hospital  for 
a  period  of  three  years 224 

Family  record  card.  Social  Service  Department,  Boston 
Dispensary 225 

Individual  record  card,  following  family  record  card. 
Social  Service  Department,  Boston  Dispensary  .  .  226 

Record  form  used  by  Social  Service  Department,  Uni- 
versity of  Pennsylvania  Hospital 227 

Record  form  used  by  Social  Service  Bureau,  Bellevue  and 
Allied  Hospitals  (Face) 228 

Same  (Reverse) 229 

Record  form  used  by  Social  Service  Department,  Massa- 
chusetts General  Hospital 230 

Record  form  used  for  tubercular  patients.  Social  Service 
Department,  Boston  Dispensary.  .  .  .  .231 

Record  form  used  for  all  medical  histories  in  the  Chil- 
dren's Clinic,  Boston  Dispensary 232 

Ward  Record.     Children's  Hospital,  Boston  Dispensary  .   233 

Facsimiles  of  reference  slips  used  by  physicians  when  re- 
ferring patients  to  a  social  service  department  .  .  234 

Facsimile  of  reference  slip  used  by  physician  referring 

patient  to  a  social  worker 235 

xi 


LIST   OF    FORMS 

PAGE 

Form  used  for  study  of  group  of  patients  coming  to  the 
Boston  Dispensary  (Face) 236 

Same  (Reverse) 237 

Form  used  in  efficiency  test  of  dispensary  treatment. 

Boston  Dispensary 238 

Form  used  for  survey  of  medical  records  of  Children's 
Clinic,  Massachusetts  General  Hospital  .  .  .  239 

List  of  diseases  and  social  treatment  which  they  demand  .  240 


XI! 


CHAPTER  I 
INTRODUCTORY 

THE  hospital  social  service  movement  aims 
to  throw  a  new  light  on  medical  practice  in 
our  institutions.  It  seeks  to  understand 
and  to  treat  the  social  complications  of  disease  by  es- 
tablishing a  close  relationship  between  the  medical 
care  of  patients  in  hospitals  or  dispensaries  and  the 
services  of  those  skilled  in  the  profession  of  social 
work.  It  strives  to  bring  to  the  institutionalized 
care  of  the  sick  such  personal  and  individual  at- 
tention to  the  patient's  social  condition  that  his 
recovery  may  be  hastened  and  safeguarded. 

The  physician  recognizes  physical  symptoms  and 
seeks  for  the  underlying  causes  of  disease.  The 
skilled  social  worker  recognizes  social  symptoms  of 
human  distress  and  also  seeks  their  underlying 
causes,  that  she  may  the  more  wisely  help.  Our 
large  charity  hospitals  and  dispensaries  shelter 
many  who  need  both  kinds  of  aid.  The  services  of 
doctor  and  social  worker  then  become  interde- 
pendent, just  as  the  physical  and  social  conditions 
of  the  patient  himself  are  interrelated.  This 
interdependence  of  medical  and  social  work,  not 
only  in  treatment  but  also  in  seeking  for  causes  of 
i  i 


SOCIAL   WORK    IN    HOSPITALS 

disease,  the  hospital  social  service  movement 
is  emphasizing.  It  seeks  to  find  the  common 
ground  of  medicine  and  sociology  and  to  relate 
most  effectively  the  functions  of  the  doctor  and 
the  social  worker. 

As  a  cause,  and  also  as  a  result  of  social  distress, 
disease  is  a  large  factor  in  the  plight  of  those  who 
become  dependent  on  public  and  private  charity. 
Mr.  Devine  says*  that  inquiry  into  the  physical 
condition  of  members  of  the  families  that  ask  for 
aid — without  for  the  moment  taking  any  other 
complications  into  account — clearly  indicates  that 
either  as  the  chief  cause  or  as  a  complication  due 
to  the  effect  of  other  causes,  "physical  disability 
is  ...  a  very  serious  disabling  condition  at 
the  time  of  application  in  three-fourths  .  .  . 
of  all  the  families  that  come  under  the  care  of  the 
[New  York]  Charity  Organization  Society."  Thus 
the  lessening  of  disease  is  of  importance  not  only 
for  health  and  comfort,  but  for  economic  welfare 
and  social  progress.  This  fact  makes  hospital 
social  service  a  particularly  significant  feature  of 
constructive  social  work. 

As  hospital  problems  are  social  as  well  as  medi- 
cal, two  expert  professions,  not  one  alone,  are 
needed.  Yet  only  in  the  last  few  years  have  the 
medical  and  the  social  worker  been  able  to  aid 
each  other.  Only  within  that  period  have  they 
been  able  habitually  to  meet  as  experts,  each 

*  Devine,  Edward  T.:  Misery  and  Its  Causes,  p.  54.  New  York, 
The  Macmillan  Co.,  1909. 


INTRODUCTORY 

teaching  and  each  learning  from  the  other:  both 
united  to  serve  the  patient  and  the  community. 
Both  groups  must  recognize  a  common  ground  be- 
fore they  can  reach  a  mutual  understanding.  So 
we  find  gradually  developing  this  sympathetic  in- 
terweaving of  effort  by  two  professional  groups 
that  for  a  time  struggled  separately  with  the 
problems  of  the  sick  and  dependent  in  the 
community. 

Since  the  beginning  of  the  hospital  social  service 
movement  in  1905  there  have  been  started  in  the 
United  States  over  one  hundred  social  service 
departments  in  hospitals  and  dispensaries.  Ex- 
tensive as  the  interest  has  become  we  are  not, 
after  so  short  an  experience,  justified  in  dogma- 
tizing about  either  the  function  of  the  hospital 
social  worker  or  the  proper  organization  of  the 
work.  We  are  still  pioneers.  Our  field  is  only 
beginning  to  be  surveyed.  All  the  experience 
gathered  so  far  must  be  considered  as  experimental 
material.  Nevertheless,  out  of  it  we  may  at  least 
develop  some  ideals.  A  few  fundamental  princi- 
ples have  been  evolved.  Not  only  has  it  been 
demonstrated  that  medical  and  social  interests 
are  closely  interrelated,  but  also  their  technique, 
— neither  can  reach  a  high  quality  without  similar 
excellence  in  the  other. 

The  social  worker  may  destroy  the  value  of  a 

doctor's  prescription  by  a  faulty  social  diagnosis  or 

treatment,  and  a  doctor  may  no  less  effectively 

vitiate  an  excellent  social  diagnosis  or  treatment. 

3 


SOCIAL   WORK    IN    HOSPITALS 

A  patient  for  whom  a  back  brace  was  ordered  by 
an  orthopedic  surgeon  was  found  subsequently  by 
a  social  worker  to  be  starving  herself  to  pay  for 
the  brace.  Later  a  general  physical  examination 
showed  that  she  was  suffering  from  pernicious 
anemia.  One  thing  is  certain:  a  patient  with 
pernicious  anemia  does  not  need  to  starve  herself 
for  a  back  brace;  she  will  die  soon  enough  with- 
out that.  Another  patient,  markedly  debilitated, 
came  to  the  hospital  for  a  tonic,  but  received  little 
benefit  from  the  physician  because  she  was  strug- 
gling to  care  for  herself  and  young  son  on  the  $4.50 
a  week  provided  by  a  relief  society. 

Between  the  two  extremes  there  are  many  dan- 
gers of  ineffectiveness  in  what  is  being  done  for 
the  patient  or  with  the  patient,  if  a  high  standard 
of  work  is  not  sustained.  Not  every  hospital  can 
make  the  most  effective  use  of  the  medical-social 
worker  even  though  the  latter  be  an  expert.  For 
if  the  social  worker  is  to  help  make  treatment  effective, 
good  medical  work  is  the  prime  necessity.  I  f  medical 
diagnosis  is  vague  or  faulty,  no  social  work,  how- 
ever expert,  can  compensate  for  it.  Hospital 
social  service,  as  part  of  efficient  medical  practice, 
can  develop,  therefore,  only  in  institutions  where 
the  medical  work  is  really  and  constantly  of  a 
high  grade.  In  short,  to  be  effective,  medical- 
social  work  demands  two  things:  constructive 
medical  work  and  constructive  social  work. 

In  the  pages  that  follow  an  attempt  has  been 
made,  not  to  present  a  text-book  on  hospital  social 
4 


INTRODUCTORY 

work,  but  to  offer  an  interpretation  of  what  the 
movement  means  to  some  of  those  most  closely 
in  touch  with  it.  This  is  no  time  for  dogmatic 
statements.  The  essential  thing  for  any  new 
movement  is  that  its  leaders,  while  firm  in  the  con- 
viction that  a  fundamental  truth  is  being  carried 
forward,  should  still  be  open-minded  and  plastic 
enough  to  fit  it  gradually  into  its  place  of  greatest 
usefulness. 


CHAPTER  II 

THE  BEGINNINGS  OF  HOSPITAL  SOCIAL 
SERVICE 

THE  spirit  of  service  to  the  sick  is  not  new. 
Indeed,  the  care  of  the  sick  has  been  an  un- 
failing expression  of  human  kindliness  since 
the  dawn  of  Christianity.  Early  in  the  Christian 
Era,  the  care  of  the  bodies  as  well  as  of  the  souls 
of  men  was  recognized  as  a  duty  of  the  church. 
Hospitals  were  established  and  nursing  orders 
arose  as  a  practical  expression  of  the  religious 
zeal  that  glorifies  unselfishness.  Victims  of  sin 
and  suffering  were  sought  in  their  wretchedness 
and  served  with  tender,  sympathetic  devotion. 
Throughout  the  history  of  hospitals  and  the  his- 
tory of  the  Christian  Church  the  spiritual  welfare 
of  the  sick  has  claimed  the  attention  of  the  clergy, 
and  no  hospital  today  is  without  their  ministra- 
tions. 

In  our  modern  hospitals  also  there  are  many 
persons  who  recognize  that  the  patient's  needs  are 
not  entirely  physical,  and  who  contribute  their 
share  of  cheer  and  comfort  to  the  sick.  Volunteer 
committees  of  women  have  for  many  years  visited 
patients  in  the  wards  of  various  institutions  and 
6 


BEGINNINGS    OF    HOSPITAL    SOCIAL    SERVICE 

extended  their  friendly  offices.  Busy  doctors  and 
nurses  have  done  countless  unrecorded  acts  of 
kindness  not  demanded  by  the  requirements  of 
their  professional  duties.  Thus,  the  patient's 
spiritual  needs  and  his  dependence  on  sympathy 
and  affectionate  interest  have  long  been  recog- 
nized both  in  theory  and  in  practice. 

There  are,  however,  some  fundamental  differ- 
ences between  these  intramural  attentions  and  the 
hospital  social  service  which  we  are  to  consider. 
Formerly,  neither  the  priest  nor  the  friendly  visitor 
co-operated  closely  and  constantly  with  the  doctor 
inside  or  with  the  social  workers  outside  the  hos- 
pital. It  has  remained  for  the  medical-social  work- 
ers of  the  present  day  to  supplement  the  function 
of  the  unofficial  visitors  with  a  fuller  consideration 
of  the  patients'  needs,  and  with  a  form  of  service 
that  is  now  accepted  as  an  important  element  in 
thorough  medical  treatment. 

Four  important  contributions  have  been  made 
to  the  development  of  this  new  hospital  social 
service,  which,  however,  is  quite  different  from 
any  of  them:  first,  by  the  society  for  the  after 
care  of  the  insane  in  England;  second,  by  the 
lady  almoners  in  London  hospitals;  third,  by 
visiting  nursing  in  its  various  forms;  fourth, 
by  the  methods  of  social  training  given  medical 
students  in  the  Johns  Hopkins  Hospital. 

The  first  of  these  contributions  dates  back  to 
about  1880.  The  problem  of  the  insane  is  a  pecu- 
liar one,  yet  the  principles  on  which  the  after  care 
7 


SOCIAL   WORK    IN    HOSPITALS 

of  the  insane  was  developed  in  England  are  of 
more  than  ordinary  significance  to  general  medical- 
social  service.  The  object  of  the  English  organi- 
zation known  as  the  Society  for  After  Care  of  Poor 
Persons  Discharged  Recovered  from  Insane  Asy- 
lums is  to  arrange  for  the  care  of  discharged  pa- 
tients,— especially  those  who  are  homeless, — and 
to  keep  friendly  oversight  during  the  process  of 
their  readjustment  to  community  life.  This  was 
always  done  in  close  co-operation  with  the  medi- 
cal superintendent  of  the  asylum.  The  excellent 
work  of  this  society  was  the  stimulus  for  similar 
work  in  connection  with  the  New  York  state  hospi- 
tals for  the  insane.  The  sub-committee  on  the 
after  care  of  the  insane,  of  the  State  Charities  Aid 
Association  of  New  York,  was  formed  about  the 
same  time  that  the  hospital  social  service  move- 
ment started  in  this  country.  The  work  of  this 
committee  has  been  of  such  value  that  the  plan 
has  been  adopted  in  connection  with  hospitals  for 
the  insane  in  many  other  states.* 

The  second  and  probably  most  important  con- 
tribution to  hospital  social  service  comes  from  the 
reorganization  of  the  work  of  the  lady  almoners 
by  Mr.  C.  S.  Loch  of  the  London  Charity  Organi- 
zation Society.  The  almoner  is  an  old  institution 
in  many  of  the  English  hospitals.  Mr.  Loch  saw 
possibilities  of  increased  usefulness  in  the  almoner's 
function  and  presented  his  suggestions  for  a  new 

*  See  State  Charities  Aid  Association  of  New  York,  Fourteenth 
Annual  Report,  Nov.  i,  1906.  Also  later  reports  of  its  Sub-committee 
on  After  Care  of  the  Insane. 

8 


BEGINNINGS    OF    HOSPITAL    SOCIAL   SERVICE 

interpretation  of  her  work  in  a  paper  published  in 
London  in  1892.* 

"  People  talk  of  medical  charity  as  if  it  were  a 
thing  apart,  unlike  all  other  forms  of  charity,  to 
be  regulated  by  no  principles,  to  be  bettered  by  no 
co-operation  with  others.  .  .  .  What  more 
glaring  picture  of  charitable  impotence  is  there 
than  that  destitute  persons  should  constantly 
apply  to  a  free  dispensary  for  drugs  which  cannot 
benefit  them  if  they  lack  the  necessary  food?  Or 
that,  in  the  same  illness  they  should  go  from  one 
out-patient  department,  free  or  even  part-pay  dis- 
pensary, to  another  without  any  heed  being  paid 
to  their  actual  conditions?  To  be  effectual,  even 
to  be  equitably  administered,  medical  charity 
must  act  in  alliance  with  general  charity.  Their 
cause  is  one.  Their  difficulties  are  very  similar. 
Each  will  succeed  better  with  the  help  of  the 
other." 

How  to  prevent  the  abuse  of  medical  charities 
by  those  able  to  pay,  has  long  been  a  puzzling 
problem  for  hospital  boards  and  social  workers. 
Mr.  Loch  saw  in  the  almoner  a  means  of  checking 
that  abuse.  But  in  practice  the  lady  almoner's 
function  soon  grew  to  be  much  wider  than  that 
of  mere  "inquirer."  The  first  lady  almoner  was 
appointed  in  1895  at  the  Royal  Free  Hospital  in 
London  in  accordance  with  a  plan  outlined  by 
Colonel  Montefiore  and  Mr.  Loch  in  1890.  Their 

*  See  Nineteenth  Century,  Vol.  XXXII,  pp.  303-304. 


SOCIAL   WORK    IN    HOSPITALS 

plan  as  presented  to  the  Select  Committee  of  the 
House  of  Lords  in  1890  was  as  follows: 

"There  should  be  appointed  in  every  medical 
charitable  institution  a  distributer  or  referer  of 
patients,  who  should  see  the  patients  after  they 
have  been  seen  by  the  medical  officer,  and  who, 
subject  to  the  requirements  of  the  hospital  from  the 
point  of  view  of  medical  instruction  or  gravity  of 
illness,  should  decide  as  far  as  possible  on  the 
statements  of  the  petitioners  for  relief,  and  also  as 
a  rule,  by  a  reference  of  the  case  to  a  charity  or- 
ganization committee  or  some  proper  local  organi- 
zation." 

The  lady  almoner  was  then  to  decide  whether  the 
patient's  social  condition  indicated  that  both  med- 
ical and  social  relief  were  more  suitable  under  poor 
law  provision,  or  whether  he  had  best  be  cared  for 
at  the  private  hospital  to  which  he  had  applied,  or 
whether  he  ought  to  provide  for  himself  by  going 
to  a  private  practitioner.  "On  this  plan,  each 
applicant  at  the  hospital  would  receive  relief  on 
his  first  visit,  if  necessary;  medical  requirements, 
from  the  point  of  view  of  education,  woul'd  be  met ; 
the  social  circumstance  of  the  patient  would  be 
taken  into  account,  no  less  than  the  medical ;  and 
other  than  medical  relief  would  be  forthcoming  for 
those  that  require  it." 

In  England  the  hospital  was  conceived  as  a  link 
in  the  chain  of  charitable  institutions  and  organi- 
zations, and  the  lady  almoner  was  regarded  as  the 
expert  ready  to  bring  to  the  hospital  problems  a 

10 


BEGINNINGS    OF    HOSPITAL    SOCIAL    SERVICE 

knowledge  of  the  community  resources  and  a  mind 
trained  in  the  methods  of  social  work.  The  lady 
almoner  has  been  described  by  the  secretary  of  a 
London  hospital  as  "a  lady  who  has  had  a  period 
of  training  in  social  questions  generally,  and  es- 
pecially in  the  various  organizations  of  charitable 
help.  She  knows  all  about  Labor  Bureaus,  Emi- 
gration Societies,  Sick  Room  Aid  Societies, 
Prevention  of  Cruelty  to  Children  Societies,  Dis- 
charged Prisoners  Aid  Societies,  Home  Nursing 
Associations,  Convalescent  Homes,  Societies  for 
the  Prevention  of  the  Spread  of  Phthisis,  Provi- 
dent Dispensaries,  Poor  Law  Infirmaries,  Appren- 
ticeship Associations  and  so  on."*  In  1905,  the 
year  in  which  the  first  social  service  department 
was  established  in  the  United  States,  many  of  the 
London  hospitals  had  the  services  of  the  lady 
almoner. 

It  is  difficult  to  measure  how  much  the  work  of 
the  visiting  nurse  in  all  her  varied  services  has 
contributed  to  the  hospital  social  service  move- 
ment. She  was  an  accepted  part  of  medical  care 
in  the  homes  of  the  sick  poor  long  before  the  type 
of  hospital  social  service  which  we  are  considering 
was  established.  Though  trained  in  a  hospital,  she 
found  visiting  nursing  so  different  from  what  she 
had  learned  in  the  hospital  wards,  that  she  was 
more  and  more  in  need  of  social  knowledge.  Her 
function  was  first  conceived  as  distinctly  medical ; 

*  British  Medical  Journal,  Feb.  5,  1910. 


SOCIAL   WORK    IN    HOSPITALS 

but  she  has  been  forced  to  add  much  social  knowl- 
edge to  her  medical  training. 

The  form  of  service  which  most  resembles  hos- 
pital social  work — though  it  is  quite  distinct  in 
function — is  that  of  the  visiting  nurse  attached  to 
a  hospital  and  a  dispensary.  Sometimes  the  nurses 
visit  dispensary  patients  or  those  who  are  dis- 
charged from  the  hospital,  in  order  to  extend  or 
finish  the  medical  work  of  the  institution.  Many 
general  hospitals  and  maternity  hospitals,  as  well 
as  tuberculosis  dispensaries  and  milk  stations  for 
babies,  maintain  visiting  nurses  for  this  type  of 
work.  Not  only  in  connection  with  dispensaries 
and  hospitals  but  also  with  social  settlements  has 
the  visiting  nurse  found  a  useful  field  of  service. 

Somewhat  different  in  its  purpose  is  that  form 
of  visiting  nursing  typified  by  the  extramural  work 
done  in  connection  with  the  nurses'  training  school 
at  the  Presbyterian  Hospital  in  New  York,  and 
designed  to  broaden  the  training  of  the  nurse.  In 
1904,  student  nurses  attended  by  an  instructor 
began  to  visit  the  homes  of  the  hospital  and  dis- 
pensary patients  and  were  "taught  to  give  nursing 
care,  to  improve  hygienic  conditions,  and  to  aid 
and  encourage  the  patients  by  kindness  and  help- 
ful advice."  Thus,  patients  who  leave  the  hos- 
pital while  still  needing  surgical  dressings  are  kept 
under  supervision.  Tuberculous  patients,  sick 
children,  and  others  receive  hygienic  instruction 
and  are  kept  in  touch  with  the  dispensary  physi- 
cians. With  an  increasing  recognition  of  the  need 


BEGINNINGS    OF    HOSPITAL    SOCIAL    SERVICE 

for  social  work  in  connection  with  this  medical 
service,  a  special  nurse  was  appointed  in  1907  to 
supervise  the  social  aspects  of  this  part  of  the  nurs- 
ing instruction.  This  course  in  visiting  nursing 
is  elective  and  the  term  of  service  is  two  months. 

The  visiting  nurse  during  the  last  fifteen  years 
has  helped  to  demonstrate  the  value  of  extending 
the  services  of  the  medical  institution  into  the 
home.  As  a  result  of  her  struggle  with  such  prob- 
lems as  tuberculosis  and  infant  mortality,  she  has 
also  helped  to  call  attention  to  the  common  field 
of  the  medical  and  the  social  worker. 

The  most  significant  contribution  to  the  early 
development  of  hospital  social  service  in  the  United 
States  was  made  by  Dr.  Charles  P.  Emerson,  who 
in  1902  organized  a  group  of  medical  students  for 
social  training.  He  recognized  that  truly  effective 
medical  training  must  include  an  understanding 
of  the  background  of  the  patients'  lives  and  some- 
thing of  their  standards  of  living.  Dr.  Emerson 
describes  the  development  of  his  work  as  follows:* 

"  It  was  partly  to  aid  their  education  that  seven 
years  ago  (1902)  some  of  the  medical  students  of 
the  Johns  Hopkins  University  organized  the  first 
student  board  of  the  Charity  Organization  Society 
of  Baltimore.  They  visit  one  poor  family  or  at 
most  two  families,  assigned  them  by  this  society, 
for  weeks,  months,  or  even  for  four  years.  They 
do  what  they  can  to  improve  conditions  in  those 

*  Emerson,  C.  P.:  A  Social  Service  Department  of  a  General 
Hospital.  National  Hospital  Review,  Mar.  15,  1909. 

13 


SOCIAL   WORK    IN    HOSPITALS 

households.  No  effort  is  made  to  select  for  these 
students,  families  in  which  there  is  sickness.  The 
students  learn  how  the  poor  man  lives,  works,  and 
thinks;  what  his  problems  are;  what  burdens  he 
must  bear.  They  learn  the  intimate  relationship 
between  the  ills  of  the  physical  body  and  the  home 
environment.  They  also  learn  how  easy  it  is  to 
give  very  good  advice  which  will  add  burdens 
which  cannot  be  borne.  They  find  out  that  the 
poor  man  is  not  always  a  self-convicted  sinner  nor 
a  self-confessed  ignoramus,  and  that  he  has  his 
own  ideas  as  to  the  necessity,  and  especially  as  to 
the  possibility,  of  his  following  advice.  The  poor 
man  loves  his  vices  as  truly  as  does  the  rich  man, 
and  will  not  abandon  them  at  the  off-hand  sug- 
gestion of  a  strange  doctor.  The  students  find 
that  to  effect  a  much  needed  reform,  e.  g.,  to  keep 
the  windows  open,  they  must  win  first  the  con- 
fidence, next  the  love  of  the  poor  patient,  and  then 
stick  to  him  closer  than  a  brother  to  prevent  re- 
lapses. 

"  In  five  years  there  were  on  the  rolls  of  active 
volunteer  workers  of  the  three  students'  boards 
over  sixty  students,  or  one-quarter  of  the  entire 
enrollment  of  the  school.  They  do  not  meet  in 
the  hospital  but  in  the  offices  of  the  Charity  Or- 
ganization Society.  The  reason  for  this  was  that 
every  member  of  the  self-appointed  committee 
which  guided  this  work  was  connected  with  the 
hospital  and  was  also  a  manager  of  the  Charity 
Organization  Society;  hence  no  conflict  between 
14 


BEGINNINGS    OF    HOSPITAL    SOCIAL    SERVICE 

these  two  interests  could  arise.  All  the  patients 
at  this  hospital  who  seemed  to  need  special  social 
service  were  referred  directly  to  this  society,  but 
the  most  interesting  and  the  best  cases  for  the 
students  to  study  are  not  these  medical  cases. 
This  organized  student  work,  with  its  purpose  of 
training  doctors  in  social  service  is,  we  believe,  a 
very  important  department  of  the  hospital." 

Dr.  Emerson's  valuable  work  differed  from  the 
present  social  service  in  hospitals  in  that  he  was 
aiming  to  educate  medical  students,  not  primarily 
to  serve  hospital  patients.  His  students  visited 
many  who  were  not  sick  and  paid  no  especial  at- 
tention to  the  clinics. 

These  four  expressions  of  social  interest  were  to 
be  found  in  varying  degrees  in  many  hospitals 
previous  to  1905.  That  year,  however,  saw  the 
first  organization  of  a  social  service  department  in 
a  dispensary  and  the  beginning  of  the  present 
spread  of  enthusiasm  for  trained  social  work  in 
medical  institutions  in  the  United  States.  It  is 
well  known  that  to  Dr.  Richard  C.  Cabot  of  Bos- 
ton is  due  the  credit  for  introducing  the  social 
worker  as  a  factor  in  hospital  and  dispensary 
treatment.  Not  alone  for  the  sake  of  the  pa- 
tient's spiritual  welfare,  not  for  the  training  of 
medical  students,  nor  for  the  instruction  of  nurses, 
nor  simply  for  the  extension  of  medical  care  into 
the  homes  was  this  form  of  work  created.  Rather 
was  it  conceived  by  a  physician  who,  in  seeking  the 
improvement  of  dispensary  practice,  found  in  the 
15 


SOCIAL   WORK    IN    HOSPITALS 

social  worker  a  potent  means  for  more  accurate 
diagnosis  and  more  effective  treatment.  Miss 
Garnet  I.  Pelton,  the  pioneer  hospital  social 
worker,  helped  to  lay  the  foundation  of  the  first 
social  service  department, — that  at  the  Massa- 
chusetts General  Hospital. 

Hospital  social  service  as  we  are  to  discuss  it  in 
this  book  brings  into  consideration  a  worker  whose 
function  is  not  distinctly  medical.  While  she 
must  have  an  understanding  of  the  patient's 
physical  condition,  the  physical  condition  is  only 
one  aspect  of  the  patient  of  which  she  must  take 
account.  As  the  doctor  sees  the  diseased  organ 
not  isolated  but  as  possibly  affecting  and  being 
affected  by  the  whole  body,  so  the  hospital  social 
worker  sees  the  patient  not  merely  as  one  unfortu- 
nate person  occupying  a  hospital  bed  but  as  be- 
longing to  a  family  or  community  group  that  is 
altered  because  of  the  ill  health  of  one  member. 
The  physician  and  nurse  seek  to  strengthen  the 
general  physical  state  of  the  patient  so  that  he  can 
combat  his  disease.  The  social  worker  seeks  to 
rally  to  the  disturbed  social  condition  the  forces  of 
reinvigoration  within  him  and  within  his  environ- 
ment. Thus  the  hospital  social  worker  finds  in 
the  hospital  an  opportunity  for  supplementing 
and  reinforcing  medical  service.  Wherever  hos- 
pital social  workers  have  been  able,  for  the  sake 
of  thorough,  effective  treatment,  to  relate  their 
efforts  most  closely  to  those  of  the  doctors,  nurses, 
and  hospital  authorities  on  the  one  hand,  and  to 
16 


BEGINNINGS    OF    HOSPITAL   SOCIAL    SERVICE 

outside  social  agencies  on  the  other,  they  have 
found  their  greatest  usefulness.  They  have  dem- 
onstrated that  there  is  in  medicine  a  place  for 
trained  workers  who  devote  themselves  to  the 
study  and  understanding  of  social  disasters,  which, 
no  less  than  physical  disease,  disturb  and  cripple 
human  lives. 

I  have  said  that  the  spirit  of  service  to  the  sick 
is  not  new.  Before  proceeding  to  those  practical 
details  of  medical-social  work  with  which  this  book 
is  especially  concerned,  it  may  be  well  to  turn  back 
to  the  hospital  and  nursing  background  against 
which  all  these  details  must  be  measured  and 
without  which  their  relation  to  progressive  medi- 
cine cannot  well  be  understood. 


•7 


CHAPTER  III 
THE  HOSPITAL  BACKGROUND 

THE  story  of  the  Christian  nursing  orders, 
down  to  the  organization  of  the  Sisters  of 
Charity  under  St.  Vincent  de  Paul,  is  one  of 
devotion  and  service  to  the  sick  which  we  may 
never  hope  to  surpass,  however  much  we  may  excel 
those  earlier  workers  in  scientific  medical  knowl- 
edge. Yet  in  the  last  quarter  of  the  eighteenth 
century,  John  Howard,  in  reporting  the  conditions 
he  found  in  the  prisons  and  hospitals  of  England 
and  France,  revealed  a  black  page  in  the  history 
of  medicine  and  nursing.  His  story  not  only 
disclosed  the  ignorance  and  superstition  that 
shrouded  much  of  the  medical  practice  of  that 
day  but  also  described  institutional  conditions  so 
unsanitary  as  to  be  revolting,  and  personal  care 
of  the  sick  so  incompetent  as  to  be  intolerable. 

The  picture  that  he  drew  is  in  striking  contrast 
not  only  with  the  hospital  of  today  but  also  with 
some  of  the  earlier  types  of  hospitals  in  which  the 
dependent  as  well  as  the  sick  were  welcomed  and 
treated  with  tenderness  and  skill.  The  reforms 
in  medical  service  for  which  Howard  pleaded  and 
to  which  the  Fliedners  of  Kaiserswerth,  and  later, 
18 


THE    HOSPITAL    BACKGROUND 

Florence  Nightingale,  made  such  valuable  con- 
tributions, demanded  just  such  vigorous  measures 
as  we  see  in  the  semi-militarism  of  the  modern 
training  schools  for  nurses.*  Coincident  with  the 
reforms  in  nursing  came  marvelous  changes  in 
medical  science.  Out  of  all  this  has  evolved  the 
modern  hospital,  complex  and  technical,  prepared 
to  care  for  physical  ills  through  the  help  of  the 
specialized,  scientifically  trained  physician  and 
nurse. 

Diverse  factors  have  contributed  to  the  in- 
creased mechanical  efficiency  and  the  growing 
popularity  of  hospitals.  The  administration  of 
anaesthesia,  the  application  of  asepsis,  the  labora- 
tory as  a  diagnostic  factor,  the  larger  use  of  such 
therapeutic  measures  as  X-ray,  hydrotherapy, 
Zander  exercises,  massage — all  the  modern  refine- 
ments of  medicine,  surgery,  and  nursing  and  the 
team-work  thereby  necessitated — accent  the  econ- 
omy of  grouping  many  forms  of  medical  treatment 
in  an  institution.  The  dangerously  rapid  en- 
largement of  our  cities,  with  the  attendant 
overcrowding  in  wretched  tenements,  the  poverty, 
weakened  vitality,  and  accompanying  disease, 
necessitates  hospital  treatment  for  an  increasing 
number  of  people  not  well  cared  for  at  home. 
Another  factor  which  contributes  to  an  increasing 
attendance  at  hospitals  is  the  diminishing  prejudice 
against  them.  The  public  sees  constant  evidence 

*  See  Nutting,  M.  Adelaide,  and  Dock,  Lavinia  L.:  A  History  of 
Nursing,  Vol.  I,  pp.  203,  205,  506,  508,  517,  524.  Also  Vol.  II, 
Chapter  I.  New  York,  G.  P.  Putnam's  Sons,  1907. 

19 


SOCIAL   WORK    IN    HOSPITALS 

of  the  improved  care  of  the  sick.  The  attitude  of 
the  mother  who  leaves  her  child  in  the  hospital  is 
now  less  often  one  of  despair  than  of  hope.  Pa- 
tients who  have  been  treated  with  kindness  and 
skill  have  helped  to  establish  in  the  community  a 
justified  confidence  in  the  hospital.  Such  con- 
fidence has,  of  course,  contributed  to  greater  de- 
mands on  the  capacity  of  the  hospitals.  Again, 
the  experience  which  medical  students  have  in  the 
wards  frequently  influences  them,  when  they  be- 
come physicians,  to  seek  the  advantage  of  institu- 
tional care  for  their  private  patients. 

During  the  rapid  material  expansion  of  hospital 
accommodation,  the  attention  of  the  institution 
officers  and  trustees  has  quite  naturally  been  con- 
centrated on  the  economic  and  quasi-military  as- 
pects of  the  organization  and  on  the  problems  of 
properly  housing  and  caring  for  the  large  numbers 
of  patients  applying  for  admission.  But  with  the 
enlargement  of  the  hospital  and  the  increase  in 
administrative  work  has  come  a  division  of  func- 
tion. The  technique  of  administration  developed 
in  the  business  world  has,  in  recent  years,  been 
more  and  more  applied  to  medical  institutions. 
Details  of  the  management  of  a  hospital,  such  as 
the  investment  of  funds,  purchase  and  distribution 
of  supplies,  employment  and  supervision  of  the 
large  corps  of  employes,  care  of  the  plant,  running 
of  the  laundry,  providing  of  food,  regulation  of  the 
dietary,  and  bookkeeping,  have  necessitated  care- 
ful business  organization.  This  has  largely  en- 


THE    HOSPITAL    BACKGROUND 

gaged  the  attention  of  superintendents  and  trus- 
tees. They  have  been  setting  their  house  in  order 
and  have  had  little  time  to  study  its  environing  and 
supporting  public.  The  medical  work  of  the  hos- 
pital and  the  relation  of  the  hospital  to  the  actual 
needs  of  the  sick  applying  for  care  have  been  to  a 
great  extent  passed  over  to  the  physicians  and 
nurses. 

But  the  staff  of  physicians  and  surgeons  has  been 
organized,  not  for  a  sensitive  appreciation  of  what 
the  public  needs,  but  for  efficiency  and  consistency 
of  technical  service  and  for  authoritative  control  of 
the  medical  work  within  the  hospital.  The  train- 
ing schools  for  nurses,  with  their  rigid  organization 
and  severe  discipline,  have  had  their  attention 
fixed  upon  an  earnest  effort  to  wrest  from  incom- 
petence the  personal  care  of  the  sick  who  come 
within  the  hospital  walls. 

The  large  modern  hospital  with  all  its  elaborate 
organization  has  become  so  like  a  great  machine 
that  the  uninitiated  often  see  in  it  an  uncompro- 
mising militarism.  The  machinery  is  baldly  ap- 
parent, while  the  reason  for  its  existence  is  often 
obscured.  This  obscurity  is  discouraging  not 
alone  to  the  outsider  who  knows  nothing  of  hospi- 
tal life  and  organization,  but  too  often  to  those 
who  are  part  of  the  machinery  itself.  Machinery 
is  necessary;  indeed,  those  who  really  understand 
the  problems  of  hospital  administration  realize 
that  there  is  need  for  even  better  and  more  exten- 
sive application  of  business  principles  in  our  insti- 


SOCIAL   WORK    IN    HOSPITALS 

tutions  than  at  present  prevails,  and  that  not  until 
the  machinery  runs  efficiently  and  smoothly  can 
the  hospital  reach  its  most  effective  medical  ser- 
vice. Nevertheless,  smooth-working  machinery 
cannot  alone  produce  a  successful  hospital,  any 
more  than  an  imposing  edifice,  beautiful  chimes, 
cushioned  pews,  and  a  creed  can  produce  a  church. 

Because  attention  has  been  concentrated  upon 
the  internal  development  of  the  institution,  the 
hospital  has  faced  the  danger  to  which  all  institu- 
tions are  susceptible, — that  of  being  unduly  self- 
centered.  Yet  the  fact  that  it  exists  in  part  for 
the  sake  of  the  community  makes  it,  perforce,  an 
institution  the  social  aspect  of  which  no  technical 
efficiency  should  be  allowed  to  obscure. 

While  the  hospital  may  be  unconscious  of  its 
social  significance,  the  ultimate  test  of  its  useful- 
ness is  the  flexible  adjustment  between  its  perfect 
machinery  and  the  changing  needs  of  the  commun- 
ity from  which  its  patients  and  its  financial  sup- 
port are  drawn.  The  rapidly  growing  interest 
within  the  hospital  in  the  development  of  medical- 
social  service  is  evidence  of  a  desire  for  more  thor- 
ough utilization  of  hospital  facilities.  Indefinite 
and  variable  as  the  conceptions  of  this  social  ser- 
vice are,  there  is  still,  in  the  desire  for  it,  a  con- 
sciousness of  some  social  responsibility  which  in- 
terrupts the  complacency  of  the  self-centered,  self- 
satisfied  institution. 

Not  until  the  patient  was  economically  boarded 
and  lodged,  not  until  his  physical  ills  had  been  in- 


THE    HOSPITAL    BACKGROUND 

telligently  dealt  with,  could  the  hospital  physi- 
cians see  that  their  many  failures  in  treatment  were 
due  in  part  to  elements  lying  outside  the  limits 
of  conventional  medical  practice.  In  these  latter 
days  there  has  arisen  the  candid  critic  of  the  ef- 
ficiency of  hospitals  and  dispensaries  who  asks 
whether  the  treatment  prescribed  at  the  hospital 
is  carried  home;  whether  the  doctor's  advice  is 
guided  by  an  understanding  of  the  patient's  ignor- 
ance and  financial  status;  whether  there  is  a  suf- 
ficient search  for  causes  of  disease  more  remote 
than  those  found  in  physical  examination  or  under 
the  microscope, — in  short,  whether  the  hospital 
is  merely  treating  the  sick  or  is  sincerely  attacking 
their  diseases  by  going  to  the  root  of  their  troubles. 
The  beginning  of  such  self  questionings  indicates  a 
developing  social  conscience  on  the  part  of  many 
who  are  engaged  in  medical  service. 

It  is  also  notable  that  the  social  worker's  recog- 
nition of  disease  as  the  greatest  cause  of  human 
misery  indicates  a  growing  appreciation  of  the 
social  significance  of  medical  work.  7'he  common 
occurrence  of  sickness  and  poverty  together  has 
long  been  recognized  as  more  than  a  coincidence. 
The  social  worker,  attacking  fundamental  prob- 
lems of  modern  life,  has  often  realized  that  he  is 
hopelessly  handicapped  without  the  aid  of  the 
medical  fraternity.  But  now  he  is  beginning  to 
act  upon  this  perception.  Medicine  and  philan- 
thropy, always  in  need  of  mutual  help  and  under- 


23 


SOCIAL   WORK    IN    HOSPITALS 

standing,  have  begun  within  the  past  decade  to 
plan  and  execute  their  work  in  common. 

What  are  the  elements  of  the  hospital  commun- 
ity, and  what  are  some  of  its  inevitable  conven- 
tions? Let  us  consider  as  a  type  a  large  general 
hospital  with  a  visiting  staff,  resident  physicians, 
laboratories,  and  nurses'  training  school. 

The  staff  physician  or  surgeon  who  gives  time 
and  skill  to  the  service  of  the  hospital  finds  there  a 
satisfaction  in  the  exercise  of  his  professional  abili- 
ties. His  skill  is  constantly  being  tested,  his  wits 
challenged.  Each  patient  presents  to  him  a  more 
or  less  interesting  and  complicated  problem.  He 
may  or  may  not  be  conscious  of  the  human  sig- 
nificance of  his  success  or  failure,  and  yet  he  may 
deal  superbly  with  the  patient's  disease.  Because 
of  his  unusual  technical  qualifications,  the  phy- 
sician is  the  most  important  element,  not  only 
in  the  treating  of  patients  but  in  the  teaching 
of  house  officers,  medical  students,  and  nurses. 
Hence  the  hospital  machinery  largely  revolves 
around  him,  and  in  the  distinctly  medical  affairs 
of  the  hospital  his  position  is  often  that  of  an 
autocrat. 

The  house  physician,  or  interne,  seeks  a  hospital 
service  because  in  preparation  for  his  professional 
life  he  is  ambitious  to  test  what  he  has  learned  in 
medical  study  and  thus  to  obtain  valuable  prac- 
tical experience.  Under  the  supervision  of  men 
whose  ability  he  respects,  he  acquires  knowledge 
24 


THE    HOSPITAL    BACKGROUND 

that  cannot  be  found  in  books.  But  naturally 
the  pressure  of  duties  upon  him  and  his  intense 
interest  in  the  technical  side  of  the  work  lead  him 
to  concentrate  on  the  strictly  "clinical  material" 
before  him.  He  usually  finds  a  great  and  quite 
engrossing  satisfaction  in  his  growing  ability  to 
understand  and  combat  disease,  and  in  the  in- 
creasing responsibility  given  him.  He  has  little 
attention  left  for  the  psychical  and  social  sides  of 
his  patients'  lives. 

The  hospital  life  and  atmosphere  stamp  them- 
selves most  definitely  upon  the  nurse.  She  volun- 
tarily subjects  herself  to  the  discipline  of  the  train- 
ing school  in  order  to  prepare  herself  for  her  chosen 
profession.  Once  admitted,  she  must,  if  she  wishes 
to  remain,  subordinate  herself  to  the  regulations 
of  the  school  and  hospital.  At  a  very  impression- 
able period  of  her  life  she  spends  almost  every  hour 
of  three  years  within  the  hospital  walls.  During 
these  three  years  her  mental  processes  are  directed 
into  conventional  grooves.  Her  work  is  exacting 
and  fatiguing.  In  most  training  schools  of  good 
standing,  the  discipline  is  military;  there  is  more 
self-repression  than  self-expression;  there  is  more 
emphasis  on  conforming  to  a  technical  regime  than 
on  the  development  of  individual  power.  She  is 
taught  an  intelligent  use  of  her  hands;  she  is  al- 
so taught  to  observe  carefully  signs  of  physical 
changes  in  patients;  and  she  is  given  a  practical 
though  superficial  knowledge  of  the  course  of  dis- 
ease and  of  its  treatment.  In  some  training 
25 


SOCIAL   WORK    IN    HOSPITALS 

schools  there  seems  to  be  a  tendency  to  forget 
that  nursing  has  been  established  as  an  art.  The 
pressure  of  work  is  so  great  that  there  is  little  time 
for  the  niceties  of  nursing  practice. 

In  proportion  to  the  innate  imagination  and 
sympathy  possessed  by  the  woman, — vital  quali- 
ties that  can  be  stifled  but  not  killed, — the  human 
interest  of  the  nurse  survives.  Yet  it  is  almost  im- 
possible to  keep  one's  attitude  toward  any  familiar 
object  fresh  and  sensitive.  Oft  repeated  action 
tends  strongly  to  become  unconscious  habit.  The 
nurse  who  is  under  the  stress  of  great  physical 
fatigue,  under  the  "illusion  of  routine,"  must 
gradually  come  to  take  much  of  her  work  as  a 
matter  of  course.  While  she  is  gaining  in  technical 
skill  she  is  fortunate,  indeed,  if  by  the  same  proc- 
ess she  is  not  losing  some  of  the  human  sensitive- 
ness and  responsiveness  which  she  had  before 
coming  to  the  hospital. 

Here,  then,  are  the  visiting  staff,  the  resident 
physician,  and  the  nurses,  all  parts  of  a  smooth- 
running  machine,  ready  daily  to  care  for  the  sick 
and  suffering.  But  what  of  the  patient?  The 
patient's  point  of  view  is  in  sharp  contrast  to  that 
of  nearly  everyone  he  meets.  All  about  him  he 
sees  people  apparently  indifferent  where  he  is 
excited,  comfortably  unconscious  of  his  pain, 
swiftly  and  easily  passing  him  through  their  hands 
as  a  sailor  coils  a  rope.  To  this  big,  strange  place 
he  comes,  absorbed  in  the  consciousness  of  his 
own  danger  and  discomfort,  only  to  find  he  is  one 
26 


THE    HOSPITAL    BACKGROUND 

of  many,  a  small  part  of  a  confusing  mass.  He  is 
fortunate  if  he  can  enter  into  his  hospital  experi- 
ence with  a  knowledge  of  the  language  and  with 
some  spirit  of  adventure  to  meet  the  incidents  of 
his  life  there.  Too  often,  however,  the  hospital 
expects  him  to  conform  to  rules  and  standards 
which  he  does  not  comprehend  and  to  which  he 
sometimes  cannot  quickly  adjust  himself.  Fortu- 
nately, his  residence  and  experience  in  the  hospi- 
tal leave  him  with  a  more  appreciative  understand- 
ing of  the  whole  regime,  and  he  leaves,  especially 
if  he  has  had  the  good  fortune  wholly  to  regain  his 
health,  with  a  sense  of  gratitude  for  what  has  been 
done  for  him. 

Obviously  the  hospital  is  a  permanent,  consist- 
ent organization  regulated  by  deep-rooted  con- 
ventions. The  ever  shifting  troops  of  patients 
form  the  unstable,  non-resisting  element, — the 
inchoate  mass  of  material  that  must  be  made  to 
fit  into  a  more  or  less  rigid,  well-ordered  routine. 
They  come  to  the  hospital  as  individuals,  but  the 
tendency  is  to  consider  them  in  bulk.  And  yet  in 
that  composite  there  exist  marked  contrasts  of 
ability  and  ignorance,  human  frailty  and  weak- 
ness, superhuman  courage  and  hopefulness  in  the 
constant  presence  of  pain  and  suffering. 

The  hospital  population  may  be  viewed  from 
many  angles  and  be  as  variously  interpreted.  The 
mind  accustomed  to  consider  disease  as  a  factor 
in  social  maladjustment  sees  in  the  train  of  all  this 
sickness,  conditions  possibly  causal,  possibly  con- 
27 


SOCIAL   WORK    IN    HOSPITALS 

tributory,  which  are  always  more  closely  related  to 
the  illness  of  the  individual  than  the  medical  spe- 
cialist alone  is  likely  to  perceive.  The  shattered 
limb  which  means  to  the  surgeon  a  demand  upon 
his  skill,  may  have  social  significance  as  a  prevent- 
able industrial  accident,  attended  by  the  tragedies 
of  unemployment  and  family  dependence.  The 
nurse,  seeing  in  the  recovery  of  the  desperately 
sick  "typhoid"  the  justification  for  her  devoted 
service,  may  have  little  conception  of  the  real 
significance  of  her  work  in  preserving  unbroken 
the  family  ties, — the  father  restored  to  the  support 
of  his  family  or  the  mother  to  the  care  of  her  chil- 
dren. The  pathologist  may  see  in  a  smear  of 
impoverished  blood  merely  a  routine  laboratory 
test,  yet  it  may  be  the  climax  in  the  story  of  a 
girl  forced  into  factory  life  to  add  a  pittance  to  the 
meager  income  of  her  deserted  mother. 

The  hospital,  in  fact,  presents  material  for  a 
social  as  well  as  a  medical  clinic.  Here  it  is  that 
one  sees  accumulated  every  type  of  social  distress, 
—a  veritable  congregation  of  "assorted  miseries." 
All  these  complications  have  been  recognized 
theoretically  by  many  hospital  authorities,  but 
practically  ignored  in  the  urgent  effort  to  care  for 
physical  ills.  Many  medical  and  social  workers 
who  are  thoughtfully  searching  for  the  causes  and 
treatment  of  human  misery  ask  whether  or  not 
the  hospital  is  ready  for  a  broadening  of  its  func- 
tion; whether  or  not  it  should  now  look  with  a 
larger  sense  of  its  opportunity  and  of  its  responsi- 


THE    HOSPITAL    BACKGROUND 

bility  beyond  its  walls  to  the  community  which  it 
more  or  less  consciously  serves.  Well  may  they 
pause  to  consider  the  real  reasons  for  the  hospital's 
existence  and  the  extent  to  which  the  patients  who 
fill  it  are  there  through  the  results  of  their  own 
unfortunate  ignorance  or  through  the  careless  in- 
difference of  society  to  the  promotion  of  its  own 
healthfulness. 

Some  thoughtful  physicians  are  recognizing  that 
in  hospital  and  dispensary  work  they  often  do  not 
get  the  results  they  work  for  and  that  this  failure 
is  partly  due  to  defects  in  hospital  methods.  What 
conditions  of  hospital  and  dispensary  work  today 
require  supplementing  in  order  to  produce  effect- 
ive results?  An  analysis  of  some  of  the  character- 
istics of  hospital  diagnosis  and  treatment  may  help 
to  show  what  the  defects  are  and  how  they  may  be 
remedied. 

Physicians  on  the  staffs  of  our  large  dispensaries 
have  more  or  less  consciously  accepted  two  differ- 
ent standards  of  medical  work:  one,  that  of  pri- 
vate practice, — the  careful  consideration  of  the 
individual  patient;  the  other,  that  of  the  over- 
crowded modern  clinic  where  a  hasty,  incomplete 
consideration  is  all  that  can  be  given  to  a  large 
majority  of  the  sick.  In  a  hospital,  physicians 
usually  limit  the  study  of  a  patient  to  purely 
physical  factors,  a  limitation  which  no  conscien- 
tious physician  would  countenance  in  private 
practice.  The  hospital  offers  him  its  assistants, 
29 


SOCIAL   WORK    IN    HOSPITALS 

its  laboratories,  and  the  instruments  necessary  for 
accurate  medical  diagnosis,  but  it  has  made  no 
provision  for  the  consideration  of  those  other  ele- 
ments in  human  beings  which  the  best  private 
practitioners  deem  of  great  importance. 

These  elements  in  the  complex  personality  of 
any  human  being  Professor  James  has  character- 
ized as  "the  material  me,  the  social  me,  and  the 
spiritual  me^^/v^v/ A  man's  me,"  he  continues, 
"is  the  sum  total  of  all  he  can  call  his,  not  only  his 
body  and  psychic  powers,  but  his  clothes  and  his 
house,  his  wife  and  his  children,  his  ancestors  and 
his  friends,  his  reputation  and  works,  his  lands  and 
houses,  his  yacht  and  bank  account."*  Many  of 
these  aspects  of  the  "me"  play  an  important  role 
in  disease  and  yet  may  be  overlooked  in  the  rapid 
working  of  an  out-patient  clinic.  Any  deep  cut  or 
wound  in  the  self,  whether  it  is  a  disturbance  of 
health,  emotions,  or  finances,  means  a  change  of 
the  whole  man. 

All  these  aspects  of  the  patient's  self  the  doctor 
in  private  practice  attempts  to  understand,  in 
order  to  be  wise  in  his  medical  treatment  and 
successful  in  his  practice.  He  knows  the  tem- 
perament of  his  patient  before  he  decides  upon 
the  rest  cure  or  the  work  cure;  he  recognizes  the 
patient's  religious  beliefs  before  he  prescribes  a 
dietary;  he  learns  the  family  finances  before  he 
advises  a  trip  to  Florida. 

*  James,  William:  The  Principles  of  Psychology,  Vol.  I,  p.  201. 
New  York,  Henry  Holt  &  Co.,  1905. 

30 


THE    HOSPITAL    BACKGROUND 

Human  beings  have  more  points  of  likeness  than 
of  difference.  Our  instincts  and  our  passions,  our 
impelling  desire  for  self  preservation,  our  love  of 
family  and  friends,  our  reverence  for  God  or  for 
an  ideal,  form  an  heritage  which  human  beings 
the  world  over  hold  in  common.  It  is  profoundly 
modified,  to  be  sure,  by  varying  inherited  traits, 
traditions,  and  standards  of  living,  ranging  from 
those  of  the  street  beggar  to  those  of  the  multi- 
millionaire. The  differences,  because  they  are 
differences,  stand  out  in  our  consciousness  as  of 
first  importance,  and  tend  to  blind  us  to  the  like- 
nesses. But  if  we  are  to  work  intelligently  with 
human  creatures,  we  must  understand  both  the 
likenesses  and  the  variations,  and  such  understand- 
ing can  come  only  with  sympathetic  observation 
and  study. 

It  is  easy  to  understand  that  in  hospital  pa- 
tients none  of  these  surprising  identities  or  modi- 
fying idiosyncrasies  of  character  and  experience 
can  be  studied  by  the  busy  physician  in  any  but 
a  superficial  way.  While  the  care  of  patients  in 
hospital  wards  offers  more  opportunity  for  obser- 
vation of  physical  conditions  than  the  dispensary 
clinic,  there  are  in  both  services  limitations  of 
time  and  a  constriction  of  the  field  of  attention 
which  mark  the  difference  between  the  physician's 
private  practice  and  his  hospital  service.  The 
limitations  of  time  as  affecting  the  observation  of 
the  hospital  patient's  physical  condition  can  be 
modified  by  better  organization  of  medical  ser- 
31 


SOCIAL   WORK    IN    HOSPITALS 

vice.  This  is  not,  however,  our  present  concern. 
The  correction  of  the  other  limitation,  that  of  the 
field  of  attention,  calls  for  supplementary  service 
from  extra-medical  fields. 


CHAPTER  IV 
MEDICAL-SOCIAL  PROBLEMS 

THE  TUBERCULOUS.    THE  CONVALESCENT.    VICTIMS  OF 
CHRONIC  DISEASE 

A  STUDY  of  hospital  social  service  through- 
out the  country  reveals  a  striking  uniformity 
in  the  problems  presented  to  the  workers, 
although  the  organization  of  the  departments  and 
methods  of  meeting  the  problems  are  very  di- 
verse. In  the  general  hospital,  the  social  workers 
struggle  with  the  questions  involved  in  dealing 
with  the  tuberculous;  patients  needing  conva- 
lescent care;  the  sick  tenement  child;  homeless 
men,  sick  and  unfit  for  work;  the  lone  young  girl 
facing  a  dishonored  motherhood;  the  industrial 
problems  of  the  physically  handicapped;  the 
feeble-minded  and  the  insane,  with  their  need  of 
protection  and  control;  the  hunted  slaves  of  drugs 
and  alcohol;  the  sufferers  from  venereal  disease 
and  its  sequelae;  the  patient  stricken  with  incur- 
able illness  needing  institutional  care;  and  the 
victims  of  black  despair  who  have  attempted  sui- 
cide. The  special  hospitals,  such  as  the  eye  and 
ear  hospitals  and  those  dealing  with  children  or 
patients  with  nervous  diseases,  have  many  prob- 
3  33 


SOCIAL   WORK    IN    HOSPITALS 

lems  peculiar  to  themselves;  but  they  are  con- 
fronted also  by  many  of  the  vexed  questions  com- 
mon to  the  general  hospitals. 

Each  patient  thus  presents  not  only  a  medical 
problem  but  a  social  one  as  well.  It  is  because  of 
the  complexity  of  the  social  problems  involved  in 
the  various  groups  of  patients,  and  the  interde- 
pendence of  the  medical  and  social  treatment,  in 
any  attempt  at  adequate  solution,  that  the  social 
worker  is  needed  in  our  hospitals.  She  does  not 
despair  at  the  diverse  woes  encountered,  because 
she  recognizes  among  social  sufferers,  as  the 
physician  does  among  the  physically  diseased, 
not  only  the  patients  who  present  chronic  and  in- 
curable conditions,  but  many  who  suffer  from  acute 
troubles  that  can  be  cured  if  skilfully  treated. 
She  recognizes  too  that  palliative  measures  may 
make  the  wretched  lot  of  many  a  chronic  sufferer 
more  bearable,  and  that  in  a  search  for  the  causes 
of  seemingly  hopeless  social  diseases,  secrets  of 
prevention  may  be  found. 

It  is  often  with  a  spirit  of  adventure  that  the 
hospital  social  worker  faces  her  day's  work.  She 
can  never  know  what  tragedies,  what  joys,  or 
what  wonders  of  human  nature  may  be  revealed 
to  her.  Animated  by  her  intimate  relation  to  the 
vital  experiences  about  her,  she  is  eager  to  con- 
tribute whatever  skill  she  may  have  to  the  service 
of  the  hospital  patients. 


MEDICAL-SOCIAL    PROBLEMS 
THE  TUBERCULOUS 

All  hospitals  face  the  problem  of  tuberculosis  in 
some  form.  Even  though  the  disease  may  not  be 
admitted  regularly  for  care,  it  appears  as  a  com- 
plication of  other  diseases.  Thus  in  our  general 
hospitals,  as  also  in  special  institutions  dealing 
with  orthopedic  and  chronic  diseases  and  with 
diseases  of  the  eye  and  throat,  we  find  not  only 
lung  tuberculosis  but  infections  of  bones  and 
glands.  While  some  elements  in  the  medical  treat- 
ment may  vary  with  the  type  of  tuberculosis, 
physicians  are  agreed  that  the  effective  treatment 
of  all  forms  of  tuberculous  infection  includes  a 
hygienic  regime.  The  program  of  this  regime 
varies  with  physicians  and  with  the  patient's  con- 
dition, but  all  medical-social  workers  must  know 
what  is  meant  by  "rest,  fresh  air,  and  good  food," 
and  how  best  to  secure  them  for  the  patient.  For 
it  is  to  the  medical-social  worker  that  the  physi- 
cian in  the  busy  dispensary  or  hospital  must  look 
to  carry  out  this  part  of  the  treatment. 

The  tuberculous  patient  presents  a  problem  not 
merely  individual  but  distinctly  social;  for  tu- 
berculosis affects  the  patient  in  all  his  social  rela- 
tions. He  is  often  a  member  of  a  family  group 
where  infection  of  others  is  threatened.  He  may 
be  living  in  a  crowded  tenement  where  darkness 
and  dirt  foster  the  life  of  the  bacilli.  He  may  be 
a  workman  in  a  dusty  factory,  or  handling  food 
which  is  sold  to  an  unsuspecting  public.  It  is 
almost  futile  to  treat  the  physical  symptoms  of 
35 


SOCIAL   WORK    IN    HOSPITALS 

the  tuberculous  patient  without  considering  and 
treating  his  social  conditions.  The  principles  of 
co-operation  are  applied  more  often  in  the  solution 
of  the  tuberculosis  problem  than  in  almost  any 
other  form  of  social  work;  for  here  we  must  have 
not  alone  the  co-operation  of  the  patient  himself, 
but  also  of  his  family,  of  local  boards  of  health, 
tenement-house  and  factory  inspectors,  and  often 
of  the  employer  and  the  church  if  we  hope  for 
any  measure  of  success. 

The  hospital  social  worker  frequently  has  the 
duty  of  breaking  to  the  patient  the  sad  news 
of  the  diagnosis,  or  at  least  of  explaining  to  him 
what,  the  doctor's  diagnosis  means,  and  of  inter- 
preting to  him  a  plan  of  treatment  that  may  prom- 
ise recovery  instead  of  the  doom  which  seems  to  be 
foretold  by  such  a  verdict.  It  is  at  this  psychologi- 
cal moment  that  the  hospital  social  workeroften  has 
an  opportunity  to  establish  that  friendly  relation 
with  the  patient  which  is  the  best  possible  basis  on 
which  to  develop  a  plan  of  treatment  for  the  victim 
of  tuberculosis.  Physicians  and  social  workers 
who  have  had  experience  with  tuberculosis  prob- 
lems realize  that  what  can  be  done  for  each  in- 
dividual patient  seems  to  depend  less  on  the  state 
of  the  disease  than  on  the  character  and  tempera- 
ment of  the  patient,  his  possibilities  of  education, 
and  the  community  resources  for  proper  treatment. 

A  weak-willed  patient  with  a  fretful  and  des- 
pondent disposition  was  sent  to  a  social  service 
department  suffering  with  incipient  tuberculosis. 
36 


MEDICAL-SOCIAL    PROBLEMS 

After  much  effort  his  family  was  provided  for  so 
that  he  might  go  to  a  sanatorium  where,  the  doc- 
tor said,  the  disease  might  be  arrested.  He  stayed 
there  two  months,  idle  and  resourceless  after  an 
active  life,  complaining  and  worrying  the  entire 
time;  then  left  against  advice  and  returned  home, 
where  he  died  a  month  later. 

Another  patient,  a  colored  porter,  emaciated 
but  with  a  fire  in  his  eye,  was  pronounced  "ad- 
vanced tuberculosis — not  a  hopeful  case."  He 
was  too  ill  to  be  admitted  into  the  sanatorium,  for 
only  incipient  cases  were  accepted.  He  was, 
however,  ready  to  make  a  fight.  Admission  being 
secured  to  a  tuberculosis  class,  he  followed  ex- 
plicitly all  directions,  slept  out  of  doors  eyen  in  the 
coldest  weather,  and  accepted  in  a  wholesome  spirit 
the  aid  that  was  provided  for  his  family.  After 
a  year  and  a  half  he  was  able  to  work.  For  five 
years  he  has  now  himself  provided  for  his  family. 
He  has  also  demonstrated  practical  lessons  in 
hygiene  that  have  affected  a  whole  neighborhood. 

Because  the  plan  of  treatment  for  a  tuberculosis 
patient  depends  so  largely  upon  the  home  con- 
ditions and  home  facilities  for  treatment,  on  the 
temperament  of  the  patient  and  on  his  financial 
status,  the  hospital  social  worker,  as  we  have 
seen,  becomes  an  important  element  in  the  devel- 
opment of  the  plan  by  which  the  patient  can  secure 
the  desired  "res.t,  fresh  air,  and  good  food," 
whether  in  a  sanatorium,  a  day  camp,  a  tubercu- 
losis class,  or  by  individual  supervision  at  home. 
37 


SOCIAL   WORK    IN    HOSPITALS 

To  many  social  service  departments  the  tubercu- 
losis patients  are  sent  by  the  physicians  with 
tentative  advice  as  to  the  form  of  treatment,  await- 
ing the  social  worker's  report  of  conditions  at  home 
before  a  definite  plan  of  treatment  is  developed. 
But  even  with  a  knowledge  of  the  facts,  both 
physical  and  social,  it  is  often  impossible  to  make 
ideal  arrangements  for  the  patient. 

Perhaps  one  of  the  most  tragic  situations  that 
arises  in  dealing  with  the  tuberculous  patient  is 
that  of  the  foreigner  who  has  come  from  country 
districts  in  Europe,  expecting  to  work  in  our  fac- 
tories and  to  save  enough  to  bring  his  family  to 
this  country.  The  following  story  is  not  an  un- 
usual one: 

An  intelligent  young  Greek,  tall  and  broad 
shouldered,  was  one  day  sent  to  a  social  worker 
with  a  diagnosis  of  moderately  advanced  tubercu- 
losis. His  eyes  betrayed  his  despair,  but  his 
story  could  be  secured  only  through  a  country- 
man, another  patient,  who  interpreted  for  him. 
He  had  been  a  shepherd  on  the  hills  of  Greece. 
Upon  his  arrival  in  America  he  had  gone  to  one 
of  our  mill  towns  hoping  to  earn  enough  so  that 
his  family  might  join  him.  His  hopes,  his  am- 
bitions, his  young  vigor  became  a  tiny  cog  in  the 
great  machine  of  industry  in  an  American  cotton 
mill.  In  order  to  save  all  the  money  possible  he 
shared  a  room  with  six  other  Greeks  in  a  cheap 
boarding  house.  Discovering  a  night  school  by 
chance,  he  attended  for  several  weeks  the  classes 
38 


MEDICAL-SOCIAL    PROBLEMS 

in    English,    and    was    making    rapid    progress. 

He  became  tuberculous.  His  eight  months  in 
the  United  States  entitled  him  to  no  free  sanator- 
ium care.  When  he  found  that  there  was  little 
chance  for  obtaining  medical  aid  except  as  a  state 
charge,  "a  pauper,"  and  that  dependence  on  the 
state  meant  possible  deportation  for  so  recent  an 
immigrant,  he  decided  of  his  own  accord  to  go  back 
to  his  home.  With  the  little  he  had  been  able  to 
save  out  of  his  earnings,  supplemented  by  some 
gifts  of  his  associates  in  the  mill,  he  purchased  his 
transportation.  Knowing  that  the  tuberculous 
patient  is  a  dangerous  fellow-passenger,  and  that 
the  disease  he  was  taking  back  to  his  Greek  home 
might  carry  disaster  with  it,  the  social  worker 
turned  to  a  Greek  physician,  a  friend  of  the  de- 
partment, who  offered  to  instruct  the  patient  and 
to  direct  him  to  a  physician  near  his  home  in 
Greece.  The  social  worker  received  a  letter,  some 
of  the  words  written  laboriously  in  English  but 
much  of  it  in  his  native  language,  which  announced 
his  safe  arrival  at  home.  The  rest  of  the  story 
she  has  never  known. 

So  it  is  that  our  tenements  and  our  industries 
are  constantly  sending  to  the  countries  of  Europe 
these  carriers  of  infection.  Thoughtful  social 
workers  cannot  have  a  part  in  such  incidents 
without  becoming  restlessly  conscious  that  these 
procedures  cannot  solve  our  tuberculosis  problem ; 
nor  do  they  solve  the  problem  of  the  immigrants 
who  return  home. 

39 


SOCIAL   WORK    IN    HOSPITALS 

Leaders  in  the  anti-tuberculosis  movement 
have  for  several  years  been  emphasizing  the  im- 
portance of  segregation  of  tuberculous  patients. 
It  has  been  generally  accepted  that  complete  seg- 
regation was  the  ideal  to  strive  for,  for  herein  lay 
the  solution  of  the  tuberculosis  question.  But 
experience  has  shown  not  only  that  complete  seg- 
regation is  practically  impossible  but  also  that 
segregation  in  itself  generates  problems.  The  en- 
forced idleness  in  our  present  sanatorium  regime, 
the  development  of  the  out-of-work  habit,  and  the 
abrupt  change  from  this  abnormal  life  to  the  stren- 
uousness  of  community  activities  on  discharge  from 
the  institution,  all  present  difficulties  that  tax  to 
the  utmost  the  ingenuity  and  optimism  of  tuber- 
culosis workers. 

All  of  these  vexed  questions  are  having  the 
serious  consideration  of  physicians,  tuberculosis 
nurses,  and  social  workers.  Suitable  occupation 
for  patients  under  treatment,  with  graduated 
manual  labor  as  recovery  progresses,  and  then 
careful  supervision  after  discharge,  during  the 
period  of  readjustment  to  normal  life,  are  now 
recognized  as  essential  to  thorough  treatment. 

With  the  after  care  of  sanatorium  patients  the 
hospital  social  worker  is  especially  concerned. 
Until  sanatoria  have  their  own  social  workers  for 
after  care  of  discharged  patients  it  is  important 
that  hospital  social  workers  keep  in  touch  with 
those  patients  for  whom  they  have  arranged  in- 
stitutional care.  Only  by  careful  study  of  results 
40 


MEDICAL-SOCIAL    PROBLEMS 

can  the  present  expensive  treatment  of  tubercu- 
losis be  fairly  tested. 

Many  of  the  social  problems  involved  in  the 
struggle  against  tuberculosis  were  recognized  by 
social  workers  before  the  medical  profession  was 
aroused  to  their  significance.  But  most  of  the 
problems  cannot,  it  is  plain,  be  solved  without  the 
helpful  working-together  of  those  who  are  treating 
the  physical  disease  and  those  who  are  helping  to 
make  the  medical  treatment  possible  and  effective 
through  an  understanding  of  the  social  complica- 
tions. The  provision  of  material  aid  for  the  care- 
less patient  who  refuses  hospital  care,  and  whose 
prolonged  life  further  endangers  his  family  and 
neighbors;  the  vexed  question  of  withholding  aid 
from  the  "unco-operative"  family;  the  tremen- 
dous expense  of  supplying  the  kind  of  care  which 
doctors  feel  is  necessary, — all  these  questions  are 
being  threshed  out  wherever  medical  and  social 
workers  are  making  the  fight  against  tuberculosis. 

No  community,  city,  or  state  has  yet  mastered 
its  tuberculosis  problem,  although  heroic  efforts 
are  being  made  the  country  over.  Active  anti- 
tuberculosis  societies  had  been  dealing  with  the 
medical-social  aspects  of  this  question  before  hos- 
pital social  service  was  organized.  The  hospital 
offers  merely  another  point  for  attack.  The  hospi- 
tal social  worker,  spurred  on  by  her  patients' 
crying  needs,  should  make  herself  a  part  of  any 
activity  directed  towards  the  reduction  of  tuber- 
culosis. Prevention,  through  education  in  laws  of 
41 


SOCIAL   WORK    IN    HOSPITALS 

hygiene,  is  a  slow  measure;  but  it  must  be  taught 
by  every  social  worker  if  she  hopes  to  do  her  part. 
The  opportunity  for  spreading  the  gospel  of  fresh 
air,  food,  and  rest,  is  offered  every  day.  Not  only 
the  patient  himself,  but  those  through  whom  the 
plan  for  his  care  must  be  carried  out,  offer  further 
openings  for  the  entrance  of  the  light.  The  fam- 
ily, the  friends,  the  church,  the  employers,  learn 
that  nature's  aids  in  fighting  tuberculosis  are  not 
drugs  to  destroy  the  enemy,  but  constructive 
agents  to  build  up  resistance  within  the  body  it- 
self. The  knowledge  of  the  significance  of  the 
tuberculosis  problem,  its  tragedies  in  blasted  hopes 
and  personal  losses,  and,  most  of  all,  its  prevent- 
able nature,  has  aroused  us,  as  no  less  cruel  de- 
stroyer could  have  done,  to  our  duty  of  providing 
better  conditions  of  work  and  living,  and  better 
means  of  health-education  for  future  generations. 

THE  CONVALESCENT 

The  need  of  opportunities  for  proper  convales- 
cence of  patients  discharged  from  hospital  wards 
has  long  been  in  the  minds  of  hospital  authorities. 
But  this  need  has  been  made  even  more  vivid  by 
the  hospital  social  workers,  who  not  only  see 
patients  leaving  the  hospital  before  they  are  fit 
for  return  to  normal  life,  but  see  also  the  grievous 
results  of  an  incomplete  recovery.  The  expense  of 
keeping  patients  in  the  wards  until  entirely  well, 
and  the  continual  pressure  of  applications  for 
care  of  new  patients,  argue  strongly  for  a  con- 
42 


MEDICAL-SOCIAL    PROBLEMS 

valescent  ward  or  department  connected  with 
each  hospital.  Under  such  a  plan  the  per  capita 
cost  of  efficient  medical  work  is  greatly  reduced 
and  the  regime  of  the  convalescent's  life  can  be 
better  suited  to  his  condition.  The  hospital  social 
worker  has  been  responsible  for  focusing  a  much 
increased  demand  on  such  convalescent  homes  as 
the  community  already  affords,  and  also  for  de- 
veloping, through  boarding  in  the  country,  or 
home  supervision,  other  methods  of  completing 
the  recovery  of  the  patient.  There  is,  also,  an  in- 
creasing tendency  to  use  the  convalescent  homes 
for  measures  of  prevention,  by  sending  many 
patients  there  who  are  debilitated,  as  well  as  others 
who  are  actually  convalescent. 

While  not  underestimating  the  value  of  con- 
valescent homes,  some  hospital  social  workers  have 
perceived  that  their  use  may  have  dangers.  The 
delightfully  irresponsible  life  of  an  inmate  of  a 
convalescent  home  is  naturally  appealing  to  people 
of  leisurely  habits.  One  patient  who  applied  to  a 
hospital  social  worker  for  care  in  a  convalescent 
home  was  found  to  have  paid  four  visits  to  three 
convalescent  homes  within  a  year.  When  the 
doctor  was  informed  of  these  facts  he  urged  light 
work  and  gradual  return  to  self-support  as  more 
fitting  than  further  idleness.  But  this  prescrip- 
tion is  obviously  more  difficult  to  fill  than  that 
of  "convalescent  care";  hence  the  temptation  for 
social  workers  to  use  the  convalescent  home  in- 
discriminately. To  fulfill  its  greatest  usefulness  a 
43 


SOCIAL   WORK    IN    HOSPITALS 

convalescent  home  should  be  used  as  an  educa- 
tional experience  for  the  patient  and  his  family. 

A  relief  agent  sent  a  seventeen-year-old  shop 
girl  to  a  dispensary  for  physical  examination  and 
convalescent  care.  On  inquiry  by  the  hospital 
social  worker,  it  was  found  that  the  patient  was 
going  to  work  without  her  breakfast,  was  addicted 
to  immoderate  tea  drinking,  and  slept  with  a  sister 
who  refused  to  have  the  windows  open  at  night. 
A  plan  was  made  with  the  relief  society  by  which 
the  family  was  moved  to  a  more  wholesome  neigh- 
borhood; an  extra  cot  was  secured  for  the  patient 
so  that  she  could  sleep  in  a  room  by  herself.  Con- 
valescent care  was  secured  for  her  for  two  weeks, 
during  which  time  she  learned  many  lessons  in 
hygiene  which  for  a  period  of  four  years  she  has 
not  forgotten. 

Most  of  the  patients  who  come  to  the  attention 
of  our  large  hospitals  are  city  dwellers  for  whom  a 
sojourn  away  from  the  dirty,  crowded  conditions 
of  our  great  cities  is  most  beneficial.  Social  work- 
ers are  increasingly  conscious,  however,  that  con- 
valescent homes  are  not  solving  the  problems  of 
"debility"  for  those  who  must  soon  return  to  un- 
wholesome tenements  and  long  hours  of  uncon- 
genial toil.  We  may  by  occasional  periods  of  rest 
be  able  to  patch  up  the  victims  of  unwholesome 
living;  but  we  must  not  deceive  ourselves  by  think- 
ing that  we  have  been  striking  at  those  deeper 
causes  some  of  which  are  beyond  the  control  of  the 
individual  patient. 

44 


MEDICAL-SOCIAL    PROBLEMS 

For  ward  patients  a  period  of  rest  in  a  convales- 
cent home  is  often  all  that  is  needed  to  complete 
recovery.  Recuperation  of  the  debilitated  body 
is  dependent  on  several  factors,  among  which  are 
rest,  nourishing  food,  fresh  air,  and  a  contented 
mind.  Prejudices  concerning  diet  and  worry  over 
financial  matters  can  render  useless  a  patient's 
stay  in  the  most  ideal  convalescent  home.  In 
communities  where  there  are  no  resorts  for  con- 
valescents, hospital  social  workers  have  in  several 
instances  arranged  to  board  patients  in  private 
families  in  the  country,  sometimes  in  the  homes  of 
trained  nurses  who  have  married  or  with  others 
who  are  especially  fitted  to  help  debilitated  pa- 
tients to  regain  their  strength.  One  social  worker 
in  a  children's  hospital  has  succeeded  in  starting 
a  convalescent  home  in  a  farm  house  to  which  a 
few  children  at  a  time  may  be  sent  to  complete 
their  recovery.  The  experience  has  so  far  justified 
itself  that  plans  are  now  under  way  to  extend  this 
"cottage  plan"  so  that  more  groups  of  convales- 
cing children  may  have  the  benefit  of  the  personal 
attention  that  is  possible  only  when  they  are  kept 
in  small  groups.  We  are  only  beginning  to  see 
the  possibilities  and  the  problems  of  proper  con- 
valescence. Hospital  social  workers,  daily  facing 
the  needs  of  debilitated  patients,  should  in  time 
contribute  much  to  the  solution  of  the  questions 
involved  in  suitable  recuperation  for  weakened 
human  bodies,  as  well  as  to  an  understanding  of 
the  mental  and  physical  handicap  of  fatigue. 
45 


SOCIAL   WORK    IN    HOSPITALS 
VICTIMS   OF   CHRONIC    DISEASE 

Temporary  or  permanent  care  in  an  institution 
is  the  social  prescription  suggested  by  the  physi- 
cian for  many  of  the  patients  whom  he  refers  to  the 
hospital  social  worker.  Most  communities  offer 
some  institutional  care  for  the  indigent,  the  in- 
sane, the  feeble-minded,  the  tuberculous,  and  the 
chronically  ill.  The  extent  and  quality  of  such  in- 
stitutions are  varied,  but  the  fact  of  their  existence 
leads  many  social  workers  to  make  more  or  less 
indiscriminate  use  of  them.  We  have  often  the 
feeling  that  we  have  taken  the  final  step  in  the 
care  of  a  homeless  man,  physically  unfit  for  work, 
when  we  have  once  secured  almshouse  care  for 
him.  We  tend  to  forget  that  almshouse  doors 
swing  easily  either  way,  and  that  the  officials  in 
charge  know  little  as  to  the  whence  or  the  whither 
of  the  inmates'  journeyings.  There  is,  of  course, 
no  question  as  to  the  importance  of  institutional 
care  for  the  patient  whose  condition  makes  him 
a  danger  to  the  public  health,  or  who  cannot 
possibly  secure  suitable  care  at  home.  It  is  well, 
however,  to  be  mindful  of  the  possibility  of  mak- 
ing a  better  plan  for  care  of  the  patient  in  his  home 
rather  than  in  an  institution. 

One  day  a  man  of  sixty-nine  years,  with  a  weak 
heart  and  a  chronic  disease  of  the  kidneys,  was 
referred  to  a  social  service  department  with  a  note 
from  the  doctor  reading,  "This  patient  wishes  to 
go  to  the  State  Almshouse."  He  was  not  sick 
enough  for  hospital  care.  The  patient  was  a 
46 


MEDICAL-SOCIAL    PROBLEMS 

Canadian,  and  a  man  of  considerable  intelligence. 
The  story  of  his  early  life  revealed  the  fact  that 
he  had  been  a  ship  builder.  Improvidence  and 
illness  had  left  him  without  savings.  For  two 
years  he  had  been  able  to  do  little  except  run  a 
freight  elevator  in  a  building  owned  by  a  former 
associate.  Recent  attacks  of  dizziness  had  made 
him  timid  about  continuing  this  work.  With 
some  reluctance  he  admitted  that  his  wife  and 
two  sons — one  of  whom  was  "a  politician  who  has 
made  some  money" — were  living,  but  he  did  "not 
wish  to  be  dependent  on  them."  The  worker, 
after  considerable  persuasion,  secured  his  permis- 
sion to  confer  with  the  family.  The  conference 
aroused  one  of  the  sons,  the  "politician,"  to  care 
for  his  father  rather  than  to  let  him  become  a 
state  charge,  and  the  father  was  persuaded  that 
the  acceptance  of  this  plan  was  in  keeping  with  his 
spirit  of  independence. 

On  the  other  hand,  institutional  care  may  be  a 
necessary  part  of  an  effective  plan  for  medical- 
social  treatment.  A  young  man,  with  a  diagnosis 
of  hernia  and  alcoholism,  was  sent  to  an  almshouse 
hospital  for  surgical  care.  He  was  eager  to  stop 
drinking.  Arrangements  were  made  for  him  to 
remain  at  the  almshouse  for  two  months.  He  was 
then  discharged  in  good  physical  condition  and 
transferred  to  a  special  institution  for  inebriates, 
where  he  remained  for  nine  months.  As  he  was 
eager  to  make  a  fresh  start  under  different  envi- 
ronment, the  patient  was  placed  in  the  country  at 
47 


SOCIAL   WORK    IN    HOSPITALS 

a  good  job,  where  for  a  year  and  a  half  he  has  kept 
away  from  drink. 

It  is  well  for  hospital  social  workers  who  have 
marked  a  case,  "Sent  to  the  state  hospital:  case 
closed,"  to  find  out  at  the  end  of  a  week  or  two 
what  has  happened.  Such  an  inquiry  disclosed 
in  one  case  a  sad  sequel  to  the  social  worker's 
efforts  in  placing  a  patient  with  far-advanced  tu- 
berculosis in  a  hospital  for  chronic  cases.  Two 
weeks  after  the  patient's  admission  he  decided  to 
go  to  Ireland,  and  he  with  his  wife  and  four  little 
children  were  soon  on  their  way,  crowded  in  steer- 
age quarters  and  bound  for  a  town  where  the  care 
of  the  tuberculous  is  very  inadequate.  Continued 
co-operation  between  the  state  hospital  and  the 
social  worker  would  have  prevented  such  a  result. 

Patients  who  have  been  placed  either  for  tem- 
porary or  for  permanent  care  in  an  institution  may 
often  be  kept  there  contented  if  a  human  interest 
in  their  welfare  can  be  continued  through  some 
outside  person.  The  tragedy  of  a  human  being 
lost  in  an  institution  can  be  appreciated  only  by 
one  who  has  experienced  it,  or  by  one  who  is 
familiar  with  the  eager  waiting  of  the  lonely  suf- 
ferer for  a  letter  or  a  visitor.  When  there  are 
relatives  or  friends,  the  social  worker  must  try  to 
make  them  feel  the  value  of  these  little  atten- 
tions to  the  patient.  If,  by  any  chance,  the  pa- 
tient is  alone  in  this  country,  without  the  ties  of 
family  or  friends,  then,  more  than  ever,  will  the 
letter,  the  paper,  the  magazine— or,  best  of  all,  the 
48 


MEDICAL-SOCIAL    PROBLEMS 

occasional  visit — be  appreciated.  Tender  care  he 
may  receive  from  nurses  and  attendants,  but  the 
disease  is  not  the  whole  man ;  he  longs  for  some 
touch  with  the  outside  world. 

Volunteers  can  often  be  secured  who  will  under- 
take to  do  these  most  important  deeds  of  human 
kindness.  For  seven  years  one  hospital  social 
worker  has  kept  a  friendly  interest  in  a  young  girl 
with  leprosy,  who  was  snatched  away  from  com- 
munity life  to  face  exile  in  a  leper  colony.  Every 
Christmas,  every  birthday,  and  many  times  be- 
tween, papers,  books,  or  letters  are  sent  to  this 
unfortunate  girl,  that  she  may  feel  that  her  exist- 
ence is  of  some  importance  to  at  least  one  human 
being. 


49 


CHAPTER  V 
MEDICAL-SOCIAL  PROBLEMS  (CONTINUED) 

THE  UNMARRIED  MOTHER.  THE  SYPHILITIC.  THE  MENTALLY 

UNBALANCED.  THE  NEURASTHENIC.  THE  SUICIDAL. 

THE  FEEBLE-MINDED 

THE  UNMARRIED  MOTHER 

ONE  of  the  most  appealing  problems  in  hos- 
pital social  work  is  the  pathetic  plight  of 
young,  unmarried  girls  facing  maternity. 
In  the  general  hospital  their  numbers  are  often 
small  compared  to  those  of  other  groups  of  pa- 
tients, but  the  utter  need  of  the  girl  makes  the 
problem  loom  up  in  all  social  service  departments. 
The  problems  of  sex — universal  social  problems 
— are  the  least  understood.     The  social,  moral, 
physical,  and  psychical  factors  are  so  intertwined 
and  deep-seated  in  human  nature  and  in  the  or- 
ganization of  society  that  the  medical-social  worker 
must  confess  herself  at  the  outset  unfit  adequately 
to  cope  with  them.     If  she  has  a  big  human  un- 
derstanding she  will  recognize  that  the  girl  before 
her,  be  she  shrinking  and  frightened,  or  defiant 
and   hardened,   or  spiritless   and   unresisting,   is 
swayed  by  forces  both  within  and  about  her.     She 
will  also  feel  that  the  illegitimate  father  may  be  a 
50 


MEDICAL-SOCIAL    PROBLEMS 

victim  as  well.  She  will,  then,  bring  to  the  heart- 
rending tales  that  she  hears  a  breadth  of  view  and 
a  sympathy  which  is  not  the  sentimentality  so  long 
the  common  response  to  such  tragedies.  While 
bringing  the  light  of  intelligence  and  of  sympathy 
to  the  problem  of  her  patient,  she  can  add  mate- 
rially if  she  will  to  the  volume  of  evidence  that 
may  in  time  help  to  enlighten  the  study  of  causes. 

Whatever  theories  one  may  evolve  as  to  the 
justice  or  injustice  of  the  present  organization  of 
society,  one  must  grant  that  the  unmarried  mother 
of  today  must  and  does  suffer  piteously  for  break- 
ing its  laws.  Any  joy  the  experience  may  bring 
her  will  be  the  gift  of  nature  to  whose  laws  she  has 
submitted.  Since  nature's  laws  are  much  more 
fundamental  than  society's  laws,  it  is  to  the  action 
of  nature's  laws  that  the  social  worker  must  look 
for  constructive  effort  with  the  illegitimate  mother. 
If  we  can  arouse  in  the  young  mother  those  unsel- 
fish elements  which  motherhood  at  its  best  so 
marvelously  reveals,  then  we  may  sometimes  in- 
terpret to  the  girl  the  laws  of  society  which  she  has 
broken,  by  showing  her  what  obligation  to  fellow 
citizens  involves. 

Whether  this  is  the  proper  task  for  the  hospital 
social  worker  or  whether  it  should  be  the  task  of 
some  social  agency  outside  the  hospital,  is  still  a 
mooted  question.  Social  agencies  have  long  strug- 
gled with  the  problem  of  the  unmarried  mother 
and  her  child.  A  social  service  department  does 
well  to  study  what  facilities  the  community  offers 
51 


SOCIAL   WORK    IN    HOSPITALS 

to  meet  this  tangled  social  question  before  install- 
ing a  special  worker  to  deal  with  such  cases.  In 
undertaking  the  oversight  of  the  unmarried  moth- 
ers, the  department  must  face  the  necessity  not 
merely  of  carrying  them  through  the  period  of 
confinement,  but  often  of  keeping  in  close  touch 
with  them  for  many  years.  The  physical  pain 
that  these  mothers  must  endure  is  trilling  in  com- 
parison with  the  mental  suffering  the  world  metes 
out  to  them,  no  matter  how  bravely  they  may  face 
their  responsibilities.  A  sympathetic  and  helpful 
friendship  must  last  out  a  lifetime  in  order  ade- 
quately to  share  the  mother's  tragedy. 

There  are  several  advantages  to  the  worker 
whose  task  of  befriending  pregnant  girls  has  its 
initial  stages  in  a  hospital  social  service  depart- 
ment. First  of  all,  she  has  the  opportunity  to 
talk  with  the  patient  at  the  psychological  moment 
when  she  may  have  just  heard  the  diagnosis  or 
when  the  diagnosis  which  she  has  feared  through 
many  anxious  weeks  has  been  confirmed.  The 
serious  loneliness  of  the  girl  makes  her  peculiarly 
responsive  to  a  friendly  interest.  While  not  much 
may  be  accomplished  during  that  first  interview, 
it  offers  an  opportunity  for  establishing  the  rela- 
tionship on  which  any  future  plan  must  rest. 
Another  advantage  which  the  medical-social 
worker  may  have  is  the  detection  of  those  patients 
who  are  not  mentally  normal.  An  early  recogni- 
tion of  the  irresponsibility  of  an  illegitimate  mother 
may  save  years  of  painstaking  efforts  toward  the 
52 


MEDICAL-SOCIAL    PROBLEMS 

building  of  a  character  that  can  never  stand  alone. 
Custodial  care  or  complete  protection  from  moral 
danger  is  the  only  safe  plan  for  such  a  girl. 

An  attractive  young  girl  of  twenty  was  one  day 
brought  to  the  attention  of  a  hospital  social  worker. 
Simply  and  quite  unmoved,  she  discussed  the  life 
she  had  been  leading  and  the  future  before  her. 
Easily  led,  lacking  in  sensitiveness,  except  when 
her  physical  emotion  was  stirred,  she  had  been  the 
easy  prey  of  unscrupulous  men.  A  few  months  of 
observation  gave  evidence  which  was  accepted  as 
assurance  of  feeble-mindedness.  She  could  not 
be  judged  by  the  standards  nor  helped  by  the 
methods  which  apply  to  the  normal  girl.  Insti- 
tutional care  was  secured  for  her  to  the  great  relief 
of  her  family,  who  are  caring  for  her  baby.  Her 
ready  acceptance  of  the  institutional  regime,  her 
contentment  with  the  simple  life  there,  are  in 
keeping  with  the  irresponsibility  which  character- 
ized her  and  which  was  undoubtedly  at  the  root  of 
her  troubles. 

Institutional  life  for  the  feeble-minded  girl  is 
clearly  the  best  mode  of  protecting  her  from  the 
temptations  she  is  sure  to  meet,  and  society  from 
the  increase  of  the  mentally  unfit.*  On  the  other 
hand,  institutional  care  for  the  normal  girl  is  un- 
sound if  it  means  her  protection  against  tempta- 
tions which  she  must  encounter  when  she  returns 
to  community  life.  Especially  is  it  unwholesome 

*  See  Goddard,  Henry  H.:  The  Kallikak  Family.  New  York,  The 
Macmillan  Co.,  1912. 

53 


SOCIAL   WORK    IN    HOSPITALS 

if  an  emotional  religious  experience  is  continually 
stirring  in  her  elements  closely  akin  to  those  which 
have  brought  her  to  disaster.  Constructive  effort 
for  the  unmarried  mother  must  be  based  on  char- 
acteristics in  the  girl's  nature  that  will  help  her  to 
withstand  the  emotional  appeal  of  the  tempta- 
tions she  will  surely  meet.  We  know  too  little  of 
the  nature  of  the  emotional  life,  whether  it  be  that 
of  sex  or  religion,  to  be  sure  that  the  religious  ap- 
peal will  always  call  forth  the  religious  strength 
to  help  through  the  hours  of  trial.  Fortunately, 
some  of  the  "rescue  homes"  are  seeing  the  truth  of 
this  fact  and  depend  more  and  more  upon  in- 
dustrial training  and  careful  following  of  the  girls 
after  they  leave  the  institution,  and  less  upon 
sudden  conversion  through  an  emotional,  religious 
appeal.  The  hospital  social  worker  before  using 
such  homes  should  know  in  detail  what  kind  of 
work  they  do.  They  frequently  offer  the  path  of 
least  resistance,  for  their  doors  are  generously  open 
as  a  refuge  to  the  girl  in  despair. 

Much  more  difficult  is  the  process  of  dealing 
with  the  girl  according  to  her  individual  needs. 
Her  nature  and  her  background  must  be  studied  to 
find  out  what  there  is  to  build  upon;  the  helpful 
co-operation  of  her  family,  her  church,  or  her 
friends  must  be  obtained.  She  must  be  made  to 
feel  the  responsibility  of  motherhood  either  through 
the  personal  care  of  her  baby  in  some  place  where 
she  can  herself  support  her  child,  or  by  arranging 
to  board  the  baby  where  she  can  see  it  often.  The 
54 


MEDICAL-SOCIAL    PROBLEMS 

human  ties  of  motherhood,  of  family,  of  church, 
must  be  strengthened  through  'a  long  period  of 
understanding  and  friendship,  so  that  she  will  be 
led  to  see  what  a  life  of  service  to  others  may 
mean. 

The  social  worker  must  recognize  that  the 
marriage  ceremony  is  no  magic  by  which  evil  is 
corrected  or  moral  character  constructed.  A 
marriage,  unless  it  is  founded  on  a  love  that  will 
give  some  promise  of  happiness,  is  hard  to  justify. 
None  the  less,  the  social  worker  must  feel  the  ob- 
ligation that  fatherhood  should  carry,  and  make 
an  effort  to  bring  a  sense  of  obligation  to  the  il- 
legitimate father  as  well  as  to  the  illegitimate 
mother.  No  artificial  plan  for  the  life  of  the  help- 
less little  baby  can  modify  the  physical  facts  of 
motherhood  or  of  fatherhood.  If  there  is  no 
marriage,  it  is  always  wisest  to  protect  by  legal 
procedure,  whether  in  court  or  through  a  private 
lawyer,  any  arrangement  for  the  support  of  the 
child  and  mother  by  the  father.  Most  social  ser- 
vice departments  secure  the  services  of  a  lawyer 
who  is  willing  to  help  in  the  tangles  which  these 
problems  involve. 

There  is  conviction  in  the  minds  of  many  social 
workers  that  this  problem  of  the  unmarried  mother 
is  not  so  much  the  problem  of  the  mother  as  it 
is  the  problem  of  the  illegitimate  child.  Coming 
into  the  world  without  the  safeguard  of  a  home, 
without  the  protection  of  a  father,  and  sometimes 
without  that  of  a  mother,  he  is  sorely  handicapped. 
55 


SOCIAL   WORK    IN    HOSPITALS 

Children's  aid  societies  everywhere  are  dealing 
with  the  illegitimate  child  with  or  without  the 
mother.  The  Boston,  Philadelphia,  and  the  Balti- 
more children's  aid  societies,  for  instance,  con- 
sider the  illegitimate  child  as  their  charge.  In 
recognition  of  this  responsibility,  the  Boston  Chil- 
dren's Aid  Society  has  made  an  arrangement  with 
the  social  service  department  at  the  Boston  Dis- 
pensary by  which  all  unmarried  pregnant  girls 
are  referred  to  them,  and  they  undertake  the  care 
of  both  the  mother  and  the  child. 

The  technique  of  co-operation  in  this  relation- 
ship is  of  interest.  All  unmarried  pregnant  girls 
coming  to  the  Dispensary  are  referred  to  a  special 
worker.  She  secures  from  the  doctor  a  statement 
of  the  physical  condition  and  from  the  girl  only 
enough  information  for  accurate  identification — 
such  as  address  and  names  of  some  relatives — and 
for  giving  intelligent  advice.  Whatever  may  be 
secured  of  "the  story"  is  passed  on  to  the  Chil- 
dren's Aid  Society.  The  girl  is  made  to  feel  that 
she  is  being  sent  to  someone  who  will  be  sym- 
pathetically interested  in  her.  She  is  given  a  card 
of  introduction  to  the  social  worker  at  the  Chil- 
dren's Aid  Society  and  a  telephone  message  is  sent 
saying  that  she  is  to  be  expected.  In  especially 
delicate  situations  the  worker  from  the  Children's 
Aid  Society  meets  the  patient  at  the  Dispensary. 

By  this  plan  the  Dispensary  makes  the  medical 
examination  and  supervises  such  medical  care  and 
treatment  as  its  physicians  deem  advisable;  the 
56 


MEDICAL-SOCIAL    PROBLEMS 

social  work  is  done  by  the  Children's  Aid  Society. 
All  contacts  and  transfers  of  mothers  between  the 
two  offices  are  made  entirely  by  two  special  work- 
ers. Monthly  reports  are  sent  to  the  Dispensary 
by  the  Society  giving  information  to  date  of  all 
patients  referred.  The  following  are  samples  of 
the  kind  of  report: 

Mary  Delany*  has  gone  with  her  baby  to  her  parents 
in  Ireland,  who  were  eager  to  have  her  and  the  baby 
come.  She  received  $100  from  her  case  against  James 
Brett  by  settlement  out  of  court.  Mary  told  a  con- 
fused story,  which  did  not  agree  with  the  account  of 
the  other  people  in  the  house  at  the  time;  hence  it  was 
thought  best  not  to  have  a  hearing  in  court.  The 
baby  is  in  fine  condition  and  Mary  adores  her. 

Maud  Berry  is  working  in  R.  at  housework.  Her 
baby  is  with  her  sister  and  Maud  is  paying  the  board 
through  us  and  is  doing  very  well. 

Margaret  Lut%  took  her  baby  home  from  the  hospital, 
a  boy  born  Oct.  4.  The  maternal  grandfather  was  ar- 
rested at  about  the  same  time  and  was  taken  from  jail 
to  the  Insane  Hospital  after  a  serious  attack  of  delirium 
tremens.  Mrs.  Lutz,  who  was  not  at  all  well,  and 
extremely  overwrought  by  these  events,  tried  to  get 
us  to  board  the  child.  Not  succeeding,  and  expecting 
the  grandfather  to  be  brought  home  dead  any  moment, 
Margaret  answered  an  advertisement  and  placed  the 
boy  at  board.  Miss  Croswell  called  next  day,  learned 
the  situation,  took  Margaret  house-hunting,  and  per- 
suaded her  to  board  the  boy  temporarily  with  the  Mas- 

*A11  names  used  in  descriptions  of  cases  in  this  book  are  ficti- 
tious. 

57 


SOCIAL   WORK    IN    HOSPITALS 

sachusetts  Baby  Hospital  while  the  family  was  moving. 
We  made  the  family  a  loan  for  moving  expenses  and 
rent  and  within  a  week  they  left  the  dingy  locality 
for  a  pleasant  home  near  the  Fells,  where  they  can 
start  over  again  among  strangers.  The  grandmother 
will  care  for  the  baby  while  Margaret  goes  to  work. 

Sadie  Mack.  Miss  Jordan,  of  the  South  Boston 
Associated  Charities,  has  consented  to  have  a  friendly 
visitor  see  Sadie  occasionally  and  try  to  get  a  stronger 
personal  hold  on  her  and  her  aunt. 

Fannie  Trimble.   Situation  unchanged. 

Jane  Clancy  could  not  get  into  the  State  Infirmary 
because  she  has  money  to  pay  on  her  confinement  ex- 
penses. St.  Mary's  refused  to  take  her.  The  Sal- 
vation Army  Home  will  take  her  but  Jane  says  she  has 
to  think  it  over  before  deciding  whether  she  will  go 
there.  If  she  does  go,  we  shall  ask  the  superintendent 
to  make  careful  observation  of  her  mentality. 

Katie  Barbarosa's  baby  was  born  at  the  State  Infirm- 
ary and  died.  She  ran  away  and  the  state  agent  en- 
deavored to  find  her  but  all  clues  are  lost. 

Minnie  Moran  (nee  Murphy)  is  living  with  her  hus- 
band in  a  home  of  their  own  in  Roxbury.  He  has 
worked  steadily  earning  $12  a  week  until  two  weeks 
ago,  when  he  gave  up  his  job  because  he  thought  it 
was  too  hard.  Then  he  was  sick  for  a  week.  The 
church  helped  them  a  little.  We  have  given  Minnie 
some  clothes.  Miss  Rhodes  has  arranged  for  her 
confinement  at  the  hospital.  We  plan  to  keep  super- 
vision until  after  the  baby  is  born  and  then  if  Moran 
is  keeping  the  home,  refer  them  to  the  Associated  Chari- 
ties for  friendly  visiting. 

58 


MEDICAL-SOCIAL    PROBLEMS 

Florence  Connor  went  to  the  State  Infirmary  and 
Miss  Mellon,  their  visitor,  has  agreed  to  supervise  her. 
She  intends  to  get  into  communication  with  the  Maine 
authorities  relative  to  the  return  of  Florence  to  her 
own  state. 

Kate  Alton  married  Mr.  Dodd  and  is  living  with  him 
in  an  apartment,  having  left  her  sister  after  quarrel- 
ing with  her.  Miss  Borden  is  visiting  Kate.  From  the 
information  we  were  able  to  get  Dodd  is  a  man  of  in- 
ferior character.  They  were  married  before  we  had 
time  to  advise  against  it. 

Fannie  O'Connor  is  still  at  St.  Mary's  where  she  was 
taken  by  her  aunt  without  her  mother's  knowledge. 
Miss  Harrison  had  a  talk  with  Mr.  O'Connor,  who 
seems  a  sensible,  honest  man  and  is  considering  taking 
Fannie  back  home. 

Bessie  Hart  was  unknown  at  the  former  address 
that  she  gave  on  Washington  St.  Inquiries  along 
Pleasant  St.,  Abington,  were  unsuccessful  and  letters 
were  returned  unclaimed. 

Annie  Farwell  gave  birth  at  home  to  a  baby  boy  on 
November  3rd.  Her  family  will  keep  her  at  home 
for  several  months,  then  a  married  sister  will  care  for 
the  child  while  Annie  works.  The  father  of  the  child 
is  not  working  and  has  shown  no  interest  since  the  first. 
Miss  Holcomb  is  planning  to  follow  him  up. 

Jennie  Cramer  is  still  with  her  foster  parents  in 
Medford.  Miss  Wilson  has  arranged  for  her  confine- 
ment at  the  Homeopathic  Hospital  and  hopes  that 
Jennie  can  go  home  with  her  baby.  The  family  are 
planning  to  move  to  another  town. 

Grace  Halsey  was  not  at  home  when  Miss  Harrison 
59 


SOCIAL   WORK    IN    HOSPITALS 

called  and  has  not  responded  to  letters.  The  young 
man's  family  had  no  idea  where  he  had  gone.  We  will 
keep  in  touch  with  Grace. 

Mary  Wilkes  has  been  placed  in  a  wage  home  under 
our  care.  Miss  Forbush  has  been  appointed  guardian. 
The  case  against  her  brother  came  to  nothing  as  Mary 
denied  that  he  was  implicated.  We  thought  that 
Mary  should  properly  be  a  state  ward,  but  the  Society 
for  Prevention  of  Cruelty  to  Children  felt  that  there 
was  not  sufficient  evidence  to  warrant  her  commit- 
ment to  the  State  Board  of  Charity,  so  we  agreed  to 
take  charge  of  her. 

THE  SYPHILITIC 

The  greatest  handicap  in  the  treatment  of  syph- 
ilis has  been  the  stigma  that  is  almost  invariably 
attached  to  it.  The  confusion  in  the  minds  of 
social  workers  that  has  led  them  to  believe  that 
syphilis  is  always  a  disgrace  and  never  an  unavoid- 
able misfortune,  has  long  hampered  helpful  co- 
operation between  physicians  and  social  workers 
in  the  attack  on  this  disease.  The  entire  lack  of 
proper  hospital  facilities  for  the  care  of  syphilis  in 
whatever  form  is  a  reflection  of  this  attitude. 
Many  relief  agencies  hesitate  to  aid  families  in 
which  there  is  syphilis.  Children's  agencies  have 
refused  to  place  at  board  children  with  late  in- 
herited syphilis  although  they  present  no  danger 
to  others. 

Every  hospital  social  worker  is  confronted  with 
the  manifestations  of  syphilis,  whether  in  the  young 
man  or  woman  who  has  acquired  it  through  ig- 
60 


MEDICAL-SOCIAL    PROBLEMS 

norance  or  immorality ;  in  the  innocent  young  wife 
whose  dreams  of  motherhood  are  hazarded  by  the 
curse  that  marriage  has  brought  to  her;  in  the 
child  facing  a  life  of  blindness  because  of  the  dis- 
ease imparted  to  it  before  birth;  or  in  the  chance 
victim  whose  health  is  jeopardized  by  the  entrance 
of  the  vicious  germ  through  a  cut  or  scratch. 

At  the  Boston  Dispensary  a  plan  of  team  work 
has  developed  between  the  social  service  depart- 
ment and  the  skin  clinic  which  is  of  much  more 
than  local  interest.  The  medical-social  worker  is 
a  part  of  the  clinic  organization, — so  much  a  part 
of  it  that  the  patients  do  not  know  "where  the 
medical  work  ends  and  the  social  work  begins." 
The  following  stories  will  tell,  although  very  in- 
adequately, something  of  the  methods  and  point  of 
view  of  the  workers,  and  of  results  that  are  being 
accomplished  there  for  the  victims  of  syphilis: 

A  little  baby  desperately  ill  with  congenital  syphilis 
and  past  the  aid  of  medicine,  was  brought  by  the  anxious 
mother  to  the  clinic,  and  very  soon  died.  The  mother, 
an  apparently  healthy  woman,  gave  a  history  of  re- 
peated miscarriages  and  told  the  medical-social  worker 
of  her  distress  in  not  being  able  to  have  healthy  children. 
Her  husband  and  his  family  had  felt  that  the  fault  was 
hers.  The  woman  consented  to  have  a  blood  test 
which  was  positive  for  syphilis.  The  family  physician, 
who  had  known  them  for  some  time,  was  asked  to 
talk  with  the  husband  to  urge  him  to  have  an  exam- 
ination and  treatment.  After  a  diagnosis  of  syphilis 
was  made  on  the  husband,  the  family  physician  ex- 
61 


SOCIAL   WORK    IN    HOSPITALS 

plained  to  him  the  nature  of  his  disease,  and  for  the 
first  time  he  realized  that  he  was  responsible  for  the 
trail  of  miseries  that  he  and  his  wife  had  suffered. 
They  are  both  having  regular  treatment. 

A  young  girl  of  sixteen,  suffering  from  syphilis  in  a 
very  infectious  stage,  came  to  the  dispensary  for  treat- 
ment. She  gave  a  false  name  and  refused  at  first  to 
answer  questions.  She  acted  as  though  she  expected 
harsh  judgment  and  certainly  no  sympathetic  interest. 
The  infectious  nature  of  her  disease  and  the  necessity 
for  treatment  were  explained.  After  a  time  she  saw 
that  the  interest  in  her  was  real  and  was  willing  to 
give  her  confidence.  The  story  as  revealed  by  later 
social  investigation  was  one  of  a  wretched  childhood 
with  an  unsympathetic  mother,  early  industrial  life, 
small  pay,  and  the  development  of  a  friendship  with  a 
girl  who  had  a  court  record  and  to  whose  bad  influence 
she  had  succumbed.  The  patient  was  treated  with 
salvarsan  and  soon  ceased  to  be  a  danger  to  others. 
A  private  society  helped  in  the  plan  for  giving  her  a 
fresh  start.  She  is  now  making  a  good  record  in  a 
private  family  and  being  kept  under  medical  super- 
vision. 

An  intelligent  young  woman,  a  widow,  came  to  the 
clinic  with  an  accidental  syphilitic  infection  on  the  lip. 
The  medical-social  worker  found  that  she  was  support- 
ing herself,  her  child,  and  her  mother  by  candy  pack- 
ing. She  was  eager  to  carry  out  the  treatment.  A 
plan  was  made  by  which  the  patient  stayed  at  home 
and  the  mother  went  out  to  work.  So  for  several 
weeks  this  patient  was  kept  under  careful  supervision 
until  she  was  no  longer  infectious. 

Another  widow,  a  mother  of  several  children,  came 
62 


MEDICAL-SOCIAL    PROBLEMS 

also  to  the  clinic  with  an  accidental  syphilitic  lesion  on 
the  lip.  She,  however,  was  not  intelligent  nor  was  she 
willing  to  carry  out  treatment.  The  social  investiga- 
tion showed  that  she  was  alcoholic  and  that  her  chil- 
dren were  sorely  neglected.  In  this  instance  the  Society 
for  the  Prevention  of  Cruelty  to  Children  took  charge 
of  the  children.  The  co-operation  of  the  Board  of 
Health  was  secured  on  the  ground  that  this  very  infec- 
tious, careless  syphilitic  was  a  menace  to  public  health. 
She  was  sent  to  an  almshouse  hospital. 

An  intelligent,  sensitive  woman  about  forty  years 
of  age  came  to  the  dispensary  because  she  had  severe 
pains  in  her  ankles,  shins,  and  back.  Plates  for  her  feet 
were  secured  but  gave  little  relief.  The  social  worker 
found  that  this  woman  had  been  the  main  support 
of  the  family  for  eight  years.  She  was  a  skilled  type- 
setter. Her  husband,  crippled  with  paralysis,  was  un- 
fit for  work.  Her  boy  of  fifteen,  a  promising  young 
fellow,  was  attending  a  commercial  high  school.  The 
care  of  the  husband  in  addition  to  her  work  proved 
too  much  for  her  and  the  medical-social  worker  ar- 
ranged for  the  husband's  temporary  transfer  to  a 
hospital.  While  making  arrangements  for  the  hus- 
band, the  worker  secured  a  history  of  his  illness  which 
she  reported  to  the  physician.  This  information  con- 
sidered in  conjunction  with  Mrs.  D.'s  persistent  head- 
aches and  pains  in  her  limbs  suggested  the  possibility 
of  specific  origin  of  her  difficulties.  An  X-ray  later 
disclosed  syphilitic  disease  in  the  bones  of  the  leg. 
Treatment  was  immediately  started  (salvarsan)  and 
she  soon  began  to  improve.  This  patient  has  never 
been  told  of  the  diagnosis.  She  was  not  infectious  and  so 


63 


SOCIAL   WORK    IN    HOSPITALS 

not  a  danger  to  others.    The  husband,   a  hopeless 
cripple,  was  carrying  the  burden  of  his  mistakes. 

These  records  present  only  a  few  of  the  difficul- 
ties, both  physical  and  social,  that  come  to  the  at- 
tention of  the  medical-social  worker  with  syph- 
ilitics. 

Treatment  of  the  victims  not  only  by  medicine, 
but  by  personal  interest,  by  patient  teaching,  and 
by  doing  all  we  can  to  prevent  the  disease  from 
spreading  in  the  home  and  outside  it,  is  essential 
to  any  adequate  plan  for  attacking  the  problem  of 
syphilis.  We  must  also  be  mindful  that  while 
many  of  the  syphilitics  are  not  venereal  infections, 
every  infection  can  be  traced  back  through  other 
individuals  to  venereal  origin.  For  this  reason  the 
problem  of  syphilis  is  a  matter  of  physical,  moral, 
and  social  concern.  It  can  be  successfully  at- 
tacked only  by  those  who  see  these  three  aspects 
and  without  prejudice  seek  to  teach  their  patients 
to  understand  their  condition  while  carrying  out 
proper  treatment. 

To  education  also  must  we  look  for  the  pre- 
vention of  syphilis, — not  education  by  knowledge 
of  the  horrors  of  the  disease,  but  by  building  de- 
cent, moral  standards  that  will  prevent  the  chain 
of  infections  that  includes  many  who  are  helpless 
and  innocent. 


MEDICAL-SOCIAL    PROBLEMS 
THE  MENTALLY  UNBALANCED 

(PSYCHONEUROLOGICAL    PATIENTS) 

The  fields  of  psychiatry  and  neurology  offer 
opportunities  for  co-operation  between  physicians 
and  social  workers  in  the  busy  hospital  or  dis- 
pensary. Among  patients  with  mental  and  ner- 
vous disorders  are  many  who  are  confronted  with 
difficulties  of  getting  along  with  other  people 
which  they  unaided  cannot  overcome;  also  many 
whose  presence  in  the  community  is  dangerous  not 
alone  for  the  community  but  for  the  patients  them- 
selves. 

Three  groups  of  patients  who  belong  to  the 
general  field  of  psychoneurology  are  now  receiving 
the  special  attention  of  hospital  social  workers. 
These  are  the  insane,  the  feeble-minded,  and  the 
psychoneurotic.  After  care  for  the  insane  was 
started  in  the  United  States  at  about  the  same 
time  that  the  movement  for  hospital  social  service 
was  initiated.  This  work,  as  we  have  seen,  had 
its  beginnings  with  the  State  Charities  Aid  Associ- 
ation in  New  York;  and  now  through  the  National 
Association  for  Mental  Hygiene  it  is  receiving  a 
new  impetus.  Our  present  interest,  however,  is 
with  the  opportunities  of  medical-social  workers 
for  service  to  insane  patients  as  they  come  to  the 
general  hospital  or  dispensary. 

Special  workers  for  insane  patients  have  been 

appointed  at  the  psychopathic  ward  at  Bellevue 

Hospital,  New  York,  and  at  the  mental  clinic  at 

the   Boston   Dispensary.     These  special  workers 

5  65 


SOCIAL   WORK    IN    HOSPITALS 

have  two  main  functions.  The  first  is  to  round  out 
the  doctor's  treatment  by  securing  for  patients 
who  need  to  be  sent  to  hospitals  for  the  insane  the 
consent  of  relatives,  and  by  making  other  necessary 
arrangements.  The  second  is  that  of  supervising 
those  who  do  not  need  institution  care.  Both 
functions  are  illustrated  in  the  following  instance: 

Max,  a  Hebrew  boy  of  eleven  years,  was  brought  to 
a  dispensary  because  he  was  "very  nervous."  The 
father  said  that  the  child  had  tried  several  times  to 
jump  out  of  the  window,  that  he  laughed  and  cried 
uncontrollably,  and  that  he  had  had  trouble  with 
his  teacher.  During  his  examination  the  child  was 
very  incoherent, — said  that  his  hair  was  on  fire,  that  he 
was  on  "the  dangerous  list," — talked  in  snatches  about 
moving  pictures  and  about  his  troubles  with  his  teacher 
who  said  he  "never  could  get  well."  A  diagnosis 
of  acute  insanity  was  made.  After  persuading  the 
father  to  sign  commitment  papers,  the  medical-social 
worker  accompanied  the  patient  and  father  to  a  psy- 
chopathic ward  of  a  hospital,  where  the  patient  was 
placed  under  careful  supervision.  His  symptoms  con- 
tinued to  be  more  and  more  violent  and  at  the  end  of  a 
week  he  was  transferred  to  a  hospital  for  the  insane. 
Meanwhile  the  medical-social  worker  had  seen  the  home, 
the  teacher,  and  the  family  physician.  The  teacher 
showed  great  interest  in  the  boy.  She  had  been  troubled 
about  his  condition  and  had  often  been  at  a  loss  to 
know  how  to  manage  him.  She  said  the  patient  had 
called  her  vile  names.  She  had  reported  this  to  the 
master  of  the  school,  who  made  him  apologize.  Other- 
wise there  had  been  no  trouble  between  them.  She 
66 


MEDICAL-SOCIAL    PROBLEMS 

supposed  that  he  was  not  properly  controlled  at  home. 
She  said  also  that  the  patient  had  been  confused  in 
his  ideas;  for  instance,  after  a  talk  on  hygiene  in  which 
sulpho-napthol  was  suggested  as  an  antiseptic  for 
bathing  cuts,  he  insisted  on  using  sulpho-napthol  as  a 
hand  lotion  until  his  hands  were  sore. 

A  home  visit  showed  the  family  living  in  a  fairly 
comfortable  tenement  although  the  building  was  dark, 
dirty,  and  in  a  crowded  district.  The  parents  seemed 
well-meaning  but  had  not  good  control  of  the  children. 
Nothing  was  found  in  the  family  history  to  show  a 
tendency  to  mental  disturbances.  As  the  patient  had 
been  a  newsboy,  the  head  of  the  club  was  seen  and  the 
report  was  confirmed  that  Max  had  been  acting  queerly 
lately.  He  had  recently  come  to  the  club  and  said  his 
father  set  him  on  fire  and  that  he  was  covered  with 
blisters.  He  was  reported  as  running  wild  on  the  streets, 
going  constantly  to  moving  picture  shows,  and  being 
erratic  about  getting  his  papers.  He  used  to  forget  to  go 
for  them,  although  he  was  sent  with  money  to  get 
them. 

The  little  fellow  was  kept  in  the  insane  hospital  for 
three  months.  When  he  was  well  enough  to  leave 
the  hospital  the  doctors  urged  most  watchful  after- 
care. As  the  home  conditions  were  unfit  hygienically, 
and  the  parents  were  very  indulgent,  they  were  urged 
to  pay  for  the  child's  board  in  the  country  until  they 
moved  to  better  quarters.  Through  a  children's 
agency  the  child  was  placed  in  a  private  home  under 
supervision,  where  he  remained  four  months.  Mean- 
time the  family  moved  farther  out  into  the  suburbs. 
They  had  learned  that  indulgence  was  not  the  greatest 
kindness  to  the  children.  When  the  child  recovered 

6? 


^          SOCIAL   WORK    IN    HOSPITALS 

he  returned  to  his  home  to  much  better  conditions. 
There  he  has  remained  for  a  year  reporting  every  two 
months  to  the  doctor. 

THE  NEURASTHENIC 

The  social  service  department  which  has  under- 
taken the  most  concentrated  social  work  for 
psychoneurotics  is  that  at  the  Massachusetts 
General  Hospital.  From  October,  1907,  to  Sep- 
tember, 1912,  Miss  Edith  N.  Burleigh  worked  in 
conjunction  with  Dr.  James  J.  Putnam  of  the 
neurological  clinic  of  the  out-patient  department, 
concerning  herself  especially  with  the  problems  of 
psychoneurotic  women.  I  can  add  nothing  to  the 
accounts  and  discussions  of  this  work  as  they  ap- 
pear in  the  annual  reports  of  the  department. 
Dr.  Putnam  writes: 

"The  physician  [in  a  dispensary]  is  apt  to  touch 
the  real  lives  of  his  patients  as  at  the  circumference 
of  a  large  wheel;  the  social  service  worker  can 
often  penetrate  more  deeply  and  may  open  avenues 
which  the  physician  can  then  follow  and  on  which 
he  may  go  still  further. 

"These  are  services  which  are  useful  in  every 
kind  of  illness,  but  particularly  useful  in  the  case 
of  patients  with  certain  disorders  of  the  nervous 
system.  For  these  patients  are  often  great  suf- 
ferers from  troubles  which  they  cannot  at  once  or 
easily  reveal,  and  indeed  do  not  clearly  under- 
stand. Their  fears,  prejudices,  and  misappre- 
hensions take  on  numberless  forms  and  are  often 
rooted  in  traditions  and  experiences  which  only 
68 


MEDICAL-SOCIAL    PROBLEMS 

long  and  intimate  contact  with  persons  of  sym- 
pathetic and  thoroughly  understanding  minds  can 
bring  to  light  and  counteract.  Such  patients 
need  moral  air  and  sunlight  and  new  outlets  for 
activity  and  thought  as  much  as  the  tubercular 
patients  need  the  physical  air  and  sunlight  through 
which  they  gain  new  holds  on  life." 

In  the  third  annual  report,  Miss  Burleigh  says: 

"A  psychoneurotic  patient  may  be  very  like  a 
'normal'  person  except  that  he  is  a  little  more 
self-centered,  more  sensitive,  more  fearful,  and 
more  swayed  by  emotions.  Yet  the  sum  of  these 
little  differences  may  make  that  patient  a  lifelong 
sufferer  from  physical  and  mental  pain,  a  burden  to 
himself  and  the  world.  The  exaggeration  of  cer- 
tain traits  and  the  deficiency  in  others  are  his  un- 
doing. 

"What  help  is  there  for  such  nervous  sufferers? 
We  think  much  can  be  done  to  re-educate  them 
through  sympathetic  interest,  by  reiterated  ex- 
planation of  the  mental  causes  of  their  trouble,  by 
encouraging  them  to  believe  in  the  possibility  of 
cure  and  to  act  upon  this  belief.  We  think,  too, 
that  the  social  worker,  acting  under  the  constant 
direction  of  the  doctor,  can  aid  in  such  re-education 
and  can  supplement  his  efforts  to  find  out  the 
causes  of  the  breakdown." 

Miss  Burleigh  has  clearly  indicated  the  value  of 
the  social  worker  in  outside  investigation  of  these 
patients.  Visits  to  the  homes  cannot  be  made  by 
the  doctors.  Such  visits  do,  however,  contribute 


SOCIAL    WORK    IN    HOSPITALS 

much  to  the  doctor's  understanding  of  the  patient 
and  often  help  both  in  treatment  and  in  diagnosis. 
Visits  to  the  home  and  to  acquaintances  of  the 
patient  are  valuable,  not  only  in  establishing 
friendly  relations  but  also  in  learning  the  back- 
ground of  the  patient's  life, — in  understanding  the 
environment  to  which  he  so  sensitively  reacts. 
They  also  make  possible  the  verification  of  the 
patient's  statements. 

A  woman  was  referred  from  a  throat  and  nose 
clinic  of  a  dispensary  to  the  nerve  clinic  because 
she  insisted  that  there  was  a  disagreeable  odor  in 
her  nose  which  examination  failed  to  account  for. 
The  patient  said  that  she  had  repeatedly  lost  her 
work  because  she  was  so  disagreeable  to  other 
people.  Visits  to  former  employers  and  to  several 
acquaintances  failed  to  find  any  proof  of  the  wom- 
an's statements.  No  one  had  been  able  to  account 
for  her  leaving  her  work  and  no  one  had  noticed 
any  odor  about  her.  These  facts  collected  through 
the  medical-social  worker  furnished  proof  of  the 
patient's  obsession  although  they  failed  to  estab- 
lish complete  conviction  in  the  patient's  mind. 
She  was,  however,  somewhat  relieved,  and  from 
time  to  time  acknowledged  that  she  might  be  mis- 
taken. A  later  development  of  tuberculosis  in 
this  patient  made  it  necessary  for  her  to  be  sent  to 
a  sanatorium.  While  there  she  became  so  much 
interested  in  the  other  patients  that  her  obsession 
about  the  odor  seemed  to  be  forgotten. 

Patients  haunted  by  phobias  can  be  treated 
70 


MEDICAL-SOCIAL    PROBLEMS 

intelligently  only  when  it  is  determined  by  the 
doctor  that  their  fears  are  not  "real."  The  ner- 
vous little  child  who  wished  that  the  bears  she 
saw  in  the  corner  were  "real"  so  that  they  could 
be  tied  up,  exemplified  the  suffering  of  these  pa- 
tients and  suggests  the  necessity  of  providing 
proper  treatment  for  them.  The  patients  do  not 
wish  to  be  haunted  by  fears  and  misgivings. 

Miss  Burleigh  tells  the  story  of  "one  patient,  who, 
broken  down  by  the  monotony  of  twenty  years' 
work  in  one  room  in  a  mill,  was  full  of  phobias  and 
much  worried  about  being  unable  to  work.  Hours 
were  spent  in  long  talks  with  her  in  an  endeavor  to 
get  at  her  philosophy  of  life.  She  was  sensitive 
and  eager  to  do  the  right  thing,  but  when  she  gave 
up  the  work  she  had  spent  her  life  in  doing  and  in 
which  she  was  interested,  she  was  at  sea,  unable 
to  adjust  herself  to  new  conditions.  In  these 
talks  the  subject  of  her  difficulties  was  threshed 
out  and  an  attempt  was  made  to  show  her  that  her 
future  depended  upon  the  way  she  took  her  life. 
She  could  become  embittered  by  its  apparent 
futility,  or  she  could  pull  herself  together,  look 
persistently  for  the  bright  side,  interest  herself  in 
the  things  and  people  about  her,  and  regard  her 
enforced  idleness  as  an  opportunity  to  rest  and 
store  up  strength.  One  day  she  said,  'When  you 
have  thought  it  all  out,  it  seems  you  know  your- 
self better/  '  I  shall  never  get  so  discouraged  with 
myself  again;  for  instance,  for  being  thin  when  I 
want  to  be  fat.'  And  again,  'Thinking  about 
7' 


SOCIAL   WORK    IN    HOSPITALS 

things  is  no  good  unless  you  get  up  and  do  some- 
thing.' Her  improvement  has  been  marked.  She 
has  made  numerous  unsuccessful  attempts  to  find 
different  and  lighter  work,  and  instead  of  being 
discouraged  by  her  failures,  is  now  contemplating 
with  interest,  even  with  eagerness,  a  return  to  her 
old  work  and  old  friends  at  the  mill." 

The  doctor  in  the  busy  clinic  cannot  spend 
enough  time  with  each  patient  to  assure  proper 
explanation  and  re-education.  Neither  can  he 
know  or  treat  the  economic  and  hygienic  aspects 
of  the  patient's  life.  What  he  does  must  be  re- 
inforced and  reiterated  again  and  again,  and  this 
can  be  done  only  by  one  who  knows  what  the  doctor 
is  striving  for  and  understands  the  mental  conflicts 
of  neurasthenic  patients.  One  who  is  ignorant  of 
mental  processes  and  who  is  lacking  in  sympathy 
and  insight  and  almost  limitless  patience  may 
undo  all  the  doctor  is  striving  to  accomplish. 

While  neurasthenia  is  more  prevalent  among 
women  than  among  men  there  is  no  less  need  for 
supplementary  social  work  in  connection  with  dis- 
pensary treatment  of  neurasthenic  men.  Owing  to 
the  subtle  elements  often  involved  in  the  mental 
life  of  these  patients  it  would  seem  best  to  leave 
the  treatment  of  this  group  to  the  physicians  and 
to  male  social  workers  when  they  are  available. 
Medical  students  and  students  of  divinity  have 
in  some  instances  served  in  the  capacity  of  medical- 
social  worker,  but  much  has  yet  to  be  done  to 
better  this  service. 

72 


MEDICAL-SOCIAL    PROBLEMS 
THE  SUICIDAL 

The  steps  by  which  men  and  women  reach  the 
pitiable  state  of  attempting  to  end  their  lives  are 
the  accumulative  agonies  of  human  souls.  The 
extent  to  which  this  morbid,  perverted  impulse 
finds  expression  in  our  large  cities  is  shocking  in- 
deed. Bellevue  Hospital,  New  York,  cares  for  an 
average  of  200  attempted  suicides  a  year.  New 
York  is  only  one  of  hundreds  of  cities  whose  hos- 
pitals are  always  open  to  save  the  life  that  seeks 
its  own  death.  The  hospital  social  worker  has  an 
unusual  opportunity  to  search  for  the  causes  back 
of  these  efforts  at  self-destruction.  While  it  may 
be  true,  as  some  believe,  that  all  persons  attempt- 
ing suicide  are,  at  least  for  the  time,  mentally  un- 
balanced, there  are  many  causal  factors,  social  as 
well  as  psychological,  that  have  led  up  to  this 
mental  bankruptcy  as  their  logical  result. 

A  woman,  an  immigrant,  was  one  day  rushed  to 
a  hospital  after  an  unsuccessful  attempt  to  commit 
suicide  in  a  detention  house  at  a  steamship  landing. 
The  day  after  her  admission  to  the  hospital  she 
made  another  attempt  to  end  her  life,  and  four 
days  later  still  another.  The  doctors  declared  her 
insane  and  therefore  unfit  for  landing  in  this 
country.  The  hospital  social  worker,  who  be- 
came interested  in  her,  found  that  she  was  a 
Russian  and  finally  secured  an  interpreter  who 
could  speak  her  language.  The  frantic  patient 
was  evidently  excited  over  her  children.  Inves- 
tigation revealed  the  following  facts: 
73 


SOCIAL   WORK    IN    HOSPITALS 

The  husband  had  come  to  this  country  a  year 
before  and  had  secured  work  in  Michigan.  He 
had  sent  for  his  family — wife  and  three  little  chil- 
dren— but  had  not  sent  the  amount  of  money  re- 
quired by  the  authorities  to  allow  them  to  land. 
The  immigration  officials  had  detained  the  mother 
and  children  until  the  husband  could  be  communi- 
cated with.  When  the  money  came  and  the  officer 
from  the  steamship  company  went  to  arrange  for 
their  transfer,  it  was  found  that  the  children  all 
had  measles.  They  were  hurried  to  a  contagious 
hospital.  The  mother,  not  understanding  this 
proceeding,  became  excited.  Other  people  in  the 
detention  house  told  her  that  the  children  had  been 
taken  and  would  be  kept  in  this  country,  and  she 
would  be  killed  or  sent  back  to  Russia.  Confused, 
in  a  strange  country,  not  understanding  the  lan- 
guage, unable  to  explain  to  herself  why  her  hus- 
band had  not  met  her,  and  panic-stricken  at  the 
loss  of  her  children,  this  outraged  mother  made 
a  frantic  effort  to  end  her  life. 

The  hospital  social  worker  became  convinced 
that  this  woman's  actions  might  be  reasonably 
explained.  She  secured  the  consent  of  the  super- 
intendent of  the  hospital  to  retain  the  patient 
until  every  possible  effort  had  been  made  to  prove 
that  she  was  not  insane.  The  co-operation  of 
the  steamship  company  was  secured.  They  tele- 
graphed to  a  representative  in  Michigan,  who  sent 
the  husband  on  at  once.  The  children,  now  fully 
recovered,  were  brought  to  the  hospital  by  a 
74 


MEDICAL-SOCIAL    PROBLEMS 

Russian  interpreter,  who  explained  carefully  to 
the  patient  that  as  soon  as  she  was  well  she  could 
go  with  the  children  to  her  husband.  The  chil- 
dren were  placed  temporarily  by  a  children's 
agency.  After  the  husband's  arrival  a  conference 
was  held  with  him,  the  doctor  from  the  immi- 
gration bureau,  the  steamship  official,  and  the 
hospital  social  worker,  and  the  following  plan  was 
devised:  The  children  were  to  be  brought  to  see 
the  mother  regularly;  the  husband  was  to  see  her 
daily;  and,  if  in  a  week's  time  she  showed  no 
further  symptoms  of  insanity,  she  was  to  be  al- 
lowed to  land  (officially!)  and  go  to  Michigan  with 
her  husband  and  children.  This  family  has  been 
for  many  months  happily  united. 

THE  FEEBLE-MINDED 

A  new  approach  to  the  problem  of  the  feeble- 
minded has  come  with  the  development  of  hos- 
pital social  service.  The  hospital  social  worker 
has  opportunity  to  get  in  touch  with  these  pa- 
tients as  they  are  brought  to  the  hospital  or  dis- 
pensary for  diagnosis,  or  are  discovered  through 
admission  for  other  diseases. 

Mary  Acker,  a  woman  of  forty,  single,  was  re- 
ferred to  a  medical-social  worker  for  immediate 
institutional  care  on  account  of  a  severe  gonor- 
rheal  infection.  With  very  little  questioning,  Mary 
poured  forth  the  story  of  her  experience  at  the 
almshouse  hospital,  where  she  had  several  years 
before  given  birth  to  a  child.  The  worker  had 
75 


SOCIAL   WORK    IN    HOSPITALS 

suggested  the  almshouse  hospital  as  the  only  place 
where  this  patient  could  be  cared  for,  and  she 
willingly  consented  to  go.  Mary  also  said  that 
she  had  for  many  years  been  in  the  school  for 
feeble-minded. 

Investigation  through  relatives,  the  school  for 
feeble-minded,  and  hospital  records  showed  that 
Mary  had  had  a  "shock  when  she  was  three  years 
of  age  and  had  neither  walked  or  talked  until  she 
was  eleven";  that  she  had  always  been  considered 
below  par  mentally,  and  that  she  had  had  two 
illegitimate  children;  also  that  she  had  been  for 
twelve  years  in  an  institution  for  the  feeble-minded. 
While  there,  she  had  so  far  improved  that  her 
mother  had  taken  her  home.  After  carefully  su- 
pervising Mary  for  three  years,  the  mother  died. 
For  the  next  three  years  Mary  had  led  an  irre- 
sponsible and  immoral  life  in  spite  of  the  desperate 
attempts  of  her  brothers  to  restrain  her.  Their 
most  eager  co-operation  was  offered  to  secure 
her  re-admission  to  the  school  for  feeble-minded. 
Through  the  superintendent  of  the  school  and 
the  superintendent  of  the  almshouse  hospital,  ar- 
rangements were  finally  made  for  the  direct  trans- 
fer of  the  patient  as  soon  as  she  was  free  from  infec- 
tion. The  report  reads:  "  Patient  went  happily  to 
— ,  where,  after  a  few  days,  she  dropped  into 
her  old  place  again  very  nicely."  Three  months 
later,  the  social  worker  visited  her  at  the  institu- 
tion and  found  her  happy  in  caring  for  some  of 
the  young  children,  to  whom  she  was  devoted. 
76 


MEDICAL-SOCIAL    PROBLEMS 

Such  morally  irresponsible  women,  "  high  grade  " 
feeble-minded,  become  a  social  problem,  because 
their  weakness  makes  them  a  temptation  and  a 
prey  to  ignorant  or  unscrupulous  men,  and  through 
them  illegitimacy  and  disease  increase  beyond  our 
ability  to  measure.  The  harmless  idiot  or  "low- 
grade"  imbecile,  on  the  other  hand,  may  need  in- 
stitutional care  only  when  it  is  a  matter  of  their 
own  humane  protection.  There  are  many  of  these 
"perpetual  babies"  who  are  most  tenderly  cared 
for  at  home.  It  is  well  for  social  workers  to  realize 
that  with  the  overcrowded  condition  of  most  of 
our  schools  for  the  feeble-minded,  it  is  often  not  so 
necessary  to  urge  institution  care  for  the  idiot  as 
it  is  for  the  higher  grades  of  feeble-minded  persons. 

One  of  the  distinct  functions  of  the  medical- 
social  worker  in  relation  to  mentally  defective 
children  is  to  see  that  all  possible  physical  defects 
are  corrected.  A  physician  frequently  pronounces 
a  child  below  par  mentally  and  urges  eye  or  ear 
examination,  removal  of  tonsils  and  adenoids, 
or  general  hygienic  treatment.  It  then  becomes 
the  task  of  the  social  worker  to  see  that  such  chil- 
dren receive  the  necessary  medical  attention  and 
so  have  an  opportunity  to  attain  normal  mental 
development,  on  the  bare  chance  that  this  may  be 
dependent  on  remediable  physical  defects. 

Our  greatest  task  in  relation  to  feeble-minded- 
ness  is  to  educate  the  community,  first,  in  the 
proper  protection  and  care  of  those  who  are  unfit 
for  self-control;  and  second,  in  the  relation  be- 
77 


SOCIAL   WORK    IN    HOSPITALS 

tween  mental  defect  and  eugenics.  In  a  compre- 
hensive paper  on  The  Burden  of  Feeble-minded- 
ness,*  Dr.  Walter  E.  Fernald  has  presented  the 
need  of  educating  physicians  in  regard  to  this 
subject.  He  says: 

"The  biological,  economic,  and  sociological 
bearings  of  feeble-mindedness  have  overshadowed 
the  fact  that  it  is  fundamentally  and  essentially  a 
medical  question.  Feeble-mindedness  is  a  con- 
dition which  is  the  result  of  certain  permanent 
lesions  of  the  central  nervous  system.  This  sub- 
ject should  receive  more  attention  in  the  medical 
schools.  At  the  present  time,  only  a  few  schools 
in  this  country  give  any  instruction  whatever  in 
the  subject.  General  hospitals  and  dispensaries 
should  have  out-patient  departments  for  the  diag- 
nosis and  treatment  of  feeble-mindedness.  These 
clinics  would  provide  for  the  instruction  of  stu- 
dents. No  medical  student  should  graduate  until 
he  has  a  general  knowledge  of  the  causes,  varieties, 
prognosis,  and  treatment  of  feeble-mindedness." 

The  skilled  hospital  social  worker,  by  the  ac- 
cumulation of  pertinent  information,  such  as  facts 
of  heredity,  school  records,  psychological  traits  and 
actions  as  seen  by  the  family  and  others  closely 
associated  with  the  patient,  can  often  bring  to 
the  attention  of  the  physician  data  which,  con- 
sidered in  conjunction  with  the  mental  examina- 
tion, will  help  both  in  diagnosis  and  in  making  the 

*  Fernald,  Walter  E.,  M.  D.:  The  Burden  of  Feeble-Mindedness. 
Boston  Medical  and  Surgical  Journal,  June  20,  1912,  Vol.  CLXVI, 


MEDICAL-SOCIAL    PROBLEMS 

best  plan  for  treatment.  She  may  also  be  able  to 
explain  to  the  parents,  the  teacher,  or  the  social 
worker,  the  curious  actions  of  4he  feeble-minded 
child, — his  lack  of  concentration  or  consistent 
ambition,  his  love  of  praise  but  lack  of  persistence 
in  effort,  his  inability  to  compete  with  normal 
children,  his  irresponsibility.  Thus  many  harsh 
judgments  may  be  avoided  and  plans  developed 
on  the  basis  of  a  better  understanding.  It  is  easy 
to  love  a  feeble-minded  child,  but  not  so  easy  to 
understand  his  simple  mental  processes. 

In  states  in  which  there  is  inadequate  provi- 
sion for  institutional  care  of  mental  defectives, 
the  combined  efforts  of  the  medical  profession  and 
the  social  workers  are  the  most  effective  means 
for  securing  protection  of  these  irresponsible 
people.  To  neglect  them  means  a  cumulative 
burden  of  illegitimacy,  venereal  disease,  and  crime 
for  the  community  to  bear. 


79 


CHAPTER  VI 
MEDICAL-SOCIAL  PROBLEMS  (CONCLUDED) 

RELIEF.  EMPLOYMENT  FOR  THE  HANDICAPPED.  MEDICAL 
ADVICE  TO  SOCIAL  AGENCIES 

RELIEF 

PATIENTS  with  evident  material  needs  are 
frequently  brought  to  the  attention  of  hospi- 
tal social  workers.     The  lack  of  proper  cloth- 
ing, the  effects  of  insufficient  food,  the  need  of  ap- 
paratus, and  worry  over  unpaid  rent  present  real 
problems,  the  solution  of  which  involves  some  of 
the  fundamental  policies  on  which  the  social  service 
department  rests.     That  these  special  needs  exist 
is  evident ;  but  as  to  the  way  in  which  they  should 
be  met  there  are  varying  opinions. 

In  some  social  service  departments  large  relief 
funds  are  raised  and  freely  drawn  upon  to  furnish 
food,  rent,  clothing,  apparatus,  and  vacations  for 
the  patients.  Such  departments  hold  that  the 
needs  are  so  clearly  related  to  physical  conditions 
as  to  be  the  responsibility  of  the  hospital  social 
worker,  and  so  of  the  department  treasury.  Other 
hospital  workers  believe  that  it  is  a  legitimate  ac- 
tivity of  a  medical  institution  to  provide  apparatus 
such  as  braces,  crutches,  and  glasses.  Still  other 
80 


MEDICAL-SOCIAL    PROBLEMS 

hospital  workers  are  convinced  that  it  is  not  the 
proper  function  of  the  hospital  in  any  of  its  de- 
partments to  give  material  relief. 

To  my  mind  the  chief  danger  of  distributing 
material  relief  as  a  regular  social  service  function, 
is  the  inevitable  tendency  to  prevent  a  clear  con- 
ception in  the  minds  of  the  patients,  the  doctors, 
and  the  workers  themselves  of  what  hospital  social 
service  is.  There  is  also  some  question  of  the  abil- 
ity of  most  hospital  social  workers  to  deal  ade- 
quately with  the  tangled  problems  of  material 
need.  Visiting  nurse  associations,  according  to 
Miss  Waters,*  have  found  it  unwise  to  allow  the 
nurses  to  assume  the  responsibility  for  distribution 
of  material  relief,  both  because  of  the  confusion 
in  the  minds  of  the  patients  and  doctors  as  to  the 
nurse's  function,  and  because  most  of  the  nurses 
have  not  been  trained  for  this  special  work.  The 
same  holds  true,  to  a  considerable  extent,  of  hos- 
pital social  workers,  who  are  largely  trained 
nurses,  many  of  whom  have  not  had  special  social 
training. 

The  hospital  social  worker  should  be  conscious 
that,  if  the  patient  needs  a  pair  of  shoes,  he  prob- 
ably needs  more;  and  that  material  things  should 
be  given  only  as  a  part  of  a  plan  for  the  patient 
that  will  tend  to  make  him  independent  of  further 
aid.  The  following  illustrations,  taken  from  the 
records  of  various  social  service  departments,  may 

*  Waters,  Yssabella:  Visiting  Nursing  in  the  United  States,  p.  17. 
New  York,  Charities  Publication  Committee,  1909. 
6  81 


SOCIAL   WORK    IN    HOSPITALS 

serve  to  indicate  possible  means  of  meeting  some 
of  the  material  needs  that  are  seen  in  hospital  cases. 

A  dispensary  physician  sent  Mr.  Sipe,  suffering 
with  a  stomach  ulcer,  to  a  medical-social  worker,  be- 
cause the  patient  said  he  could  not  carry  out  the  doc- 
tor's prescription  of  "rest  in  bed  and  special  diet  of 
milk,  cream,  eggs,  and  olive  oil."  Rest  in  bed  meant 
that  he  must  stop  work.  To  give  up  his  work  meant 
to  cut  off  all  income  for  his  family.  A  relief  agency 
was  asked  to  help  carry  out  the  treatment  that  would 
make  this  man  again  self-supporting.  Adequate  re- 
lief for  this  patient  must  include  not  only  the  special 
diet,  but  provision  for  the  family,  so  that  he  would 
not  be  tempted  to  deny  himself  and  share  his  nourish- 
ment with  his  hungry  wife  and  children.  A  plan  was 
made  by  the  relatives  and  the  relief  society  by  which 
the  financial  burden  was  fairly  distributed, — the  relief 
society  furnishing  the  food,  while  relatives  paid  the 
rent  and  met  other  necessary  expenses.  The  employer 
agreed  to  change  the  man's  occupation  when  he  might 
be  able  to  return  to  work.  He  had  been  a  sweeper  in 
a  stable,  using  a  long,  heavy  broom,  which  he  pushed 
by  pressing  his  weight  against  the  handle.  At  the 
end  of  eight  weeks  the  man  returned  to  the  stable  and 
was  given  a  job  as  driver.  For  two  years  he  has  been 
able  to  keep  well  and  at  work. 

Mr.  Coghlan,  six  feet  tall,  broad-shouldered,  and 
in  excellent  general  physical  condition,  was  one  day 
brought  to  the  social  service  department  by  an  ortho- 
pedic physician.  The  doctor  explained  that  the  man 
had  lost  his  right  arm  in  an  accident  nine  months  be- 
fore, and  that  the  left  arm  had  been  so  badly  shattered 
82 


MEDICAL-SOCIAL    PROBLEMS 

that,  although  it  had  now  healed,  it  hung  quite  help- 
less by  his  side.  The  muscles  were  sufficiently  intact 
to  give  promise  of  development  provided  the  patient 
could  have  careful  massage  and  Zander  exercises  daily 
for  two  or  three  months.  The  man's  helplessness, 
despite  his  vigorous  body,  made  it  necessary  for  him 
to  live  at  home,  some  twenty-five  miles  from  the  hos- 
pital. The  wife  had  found  work  in  a  mill,  and  for 
several  months  had  been  helping  to  care  for  the  two 
children,  her  mother,  and  her  husband.  The  $300 
savings  were  gone,  and  lodge  benefit  had  been  given 
for  the  year.  The  accident,  a  fall  from  a  defective 
trestle  at  a  railway  terminal  where  he  was  employed  as 
a  foreman  could  not,  according  to  the  then  existing 
laws,  come  under  employer's  liability.  The  chief  need 
of  this  patient  was  means  for  transportation  from  his 
home  town  to  the  hospital.  Relatives  were  already 
aiding  as  far  as  their  means  would  allow.  The  em- 
ployer promised  Mr.  Coghlan  work  as  watchman  as 
soon  as  he  was  able  to  turn  in  an  alarm.  It  chanced 
that  a  private  patient,  whose  interest  had  been  aroused 
because  he  too  had  to  take  Zander  treatment  in  the 
same  room  with  Mr.  Coghlan,  was  able  to  pay  for  Mr. 
Coghlan's  transportation,  and  did  so  for  two  months. 
The  lodge  paid  for  another  month.  Three  months' 
daily  treatment  restored  Mr.  Coghlan  to  self-support. 

Mary  Cole,  a  little  girl  of  nine,  a  victim  of  neglected 
poliomyelitis,  was  sent  to  a  social  service  department 
with  the  request  that  arrangements  be  made  to  secure 
for  her  a  $9.00  back  brace.  She  was  the  eldest  of  four 
children,  and  lived  with  her  parents  in  a  small  coast 
town.  Her  father  was  a  fisherman,  and  could  earn 

83 


SOCIAL   WORK    IN    HOSPITALS 

barely  enough  during  the  summer  to  carry  his  family 
through  the  winter.  Other  resources  failing,  little 
Mary's  need  was  called  to  the  attention  of  a  summer 
resident,  who  gladly  paid  for  the  brace. 

In  all  these  instances  time  might  have  been 
saved  if  the  worker  had  but  to  sign  a  check  for  the 
food,  rent,  carfares,  or  brace;  but  there  are  con- 
siderations more  important  than  the  saving  of 
time  in  dealing  with  human  needs.  The  social 
worker  in  order  to  know  best  how  to  administer 
material  aid  must  be  not  merely  a  careful  investi- 
gator of  the  real  cause  for  the  applicant's  need  of 
aid;  she  must  also  be  constructively  imaginative, 
and  make  the  furnishing  of  the  necessary  relief 
a  means  not  only  of  securing  food,  clothing,  or 
money,  but  also  of  strengthening  vital  ties  between 
human  beings.  These  may  be  ties  of  family,  of 
church,  of  fraternal  societies,  of  neighborhood,  of 
nationality,  or  between  people  whose  similar  ex- 
periences have  established  a  bond. 

Through  a  hospital  social  worker  a  boy  working 
in  a  shoe  shop,  although  alone  in  the  world  and 
physically  handicapped,  found  a  real  friend  in 
another  boy,  fifteen  years  old,  who,  having  more 
than  he  needed  of  the  material  things  of  this  world, 
was  asked  to  send  his  partly-worn  clothes  to 
"Billy."  But  the  friendship  was  not  established 
on  the  basis  of  the  transfer  of  coats  and  trousers. 
"The  little  feller,"  as  Billy  called  him,  recognized 
the  greater  possibilities  of  their  relationship.  The 
84 


MEDICAL-SOCIAL    PROBLEMS 

following  letter  was  the  first  of  many  in  the  de- 
velopment of  a  friendship  between  these  two  boys, 
although  they  are  in  different  cities  and  have  never 
seen  one  another. 

"Dear  William:  I  hear,  through  Miss  H,  that  you  had 
some  clothes  of  mine.  I  am  glad  of  it,  and  perhaps  later  I 
can  help  you  some  more.  I  don't  know  exactly  how  to  write 
to  you,  because  you  are  nineteen  and  I  am  only  just  barely 
fifteen.  I  am  very  much  interested  now  in  Magic,  and  I  am 
called  a  Prestidigitator.  I  can  do  a  good  many  tricks  and 
perhaps  this  Christmas,  if  you  have  a  boy's  club,  I  could 
show  you  some  of  them.  I  am  sending  you  a  card  trick  which 
you  can  do  very  easily,  and  it  is  lots  of  fun  to  mystify  people 
with  it.  I  also  send  you  some  samples  of  my  printing.  1 
have  a  little  printing  press,  and  I  printed  a  little  weekly  paper 
two  years  ago." 

The  problems  cited  are  simple  ones.  There  are 
many  more  complicated  questions,  such  as  relief 
of  the  family  of  a  deserting  or  drunken  father  whose 
children  show  physical  neglect;  or  the  tragedy  of 
the  breadwinner  who  is  facing  a  chronic  disease 
which  prohibits  not  only  his  caring  for  his  family, 
but  his  own  support.  They  involve  the  most 
painstaking  plans  and  persistent  oversight  by 
those  who  understand  that  material  relief  should 
include  also  wise,  constant  friendship.  Social 
problems  such  as  these  are  too  involved  and 
long  continued  for  a  social  service  department  to 
carry.  This  is  true  both  because  very  few  hospi- 
tal social  workers  have  been  trained  to  the  ad- 
ministration of  material  relief,  and  because  the 
85 


SOCIAL   WORK    IN    HOSPITALS 

volume  of  work,  with  its  ever-increasing  new  prob- 
lems more  or  less  exigent,  crowds  out  the  possibility 
of  caring  properly  for  the  needy  family.  We 
sometimes  forget  that  the  need  of  food  that  pre- 
sents itself  as  an  emergency  today,  demanding 
immediate  relief,  may  be  a  constantly  recurring 
emergency  for  months  to  come. 

The  giving  of  material  relief  has  so  long  been 
a  tangible  expression  of  charitable  interest  that 
many  people  do  not  realize  that  a  wise  adminis- 
tration of  material  relief  requires  special  social 
training.  A  general  social  training  does  not  nec- 
essarily prepare  one  for  the  special  branches  in 
social  work,  any  more  than  a  general  medical 
training  prepares  one  to  be  a  surgeon  or  an  ortho- 
pedist. 

The  first  consideration  of  the  hospital  social 
worker  who  sees  the  material  needs  of  her  patients 
complicated  by  family  problems,  should  be  the 
possible  facilities  which  the  community  offers  for 
meeting  those  needs.  Most  large  cities  now  have 
social  agencies  skilled  through  long  experience  in 
relief  work.  In  many  cities  the  hospital  workers 
and  secretaries  of  relief  societies  are  working  closely 
together  on  common  problems. 

Many  social  service  departments  have  loan 
funds  by  means  of  which  apparatus,  such  as 
glasses,  braces,  and  plates  can  be  secured  for  pa- 
tients who  can  pay  for  them  in  small,  regular 
amounts.  In  one  department  a  loan  fund  of  %\  50 
was  used  many  times  over  during  the  year.  The 
86 


MEDICAL-SOCIAL    PROBLEMS 

most  essential  points  to  consider  in  regard  to  loans 
are,  first,  whether  the  patient  should  undertake  to 
repay  a  loan  or  whether  relief  should  be  secured; 
second,  that  if  arrangements  are  made  for  a  loan 
they  should  be  business-like,  and  the  patient  made 
to  understand  that  he  will  be  expected  to  repay 
according  to  the  agreement.  Unpaid  loans  indicate 
faulty  work  on  the  part  of  the  social  workers  as 
much  as  irresponsibility  of  the  patients. 

EMPLOYMENT  FOR  THE  HANDICAPPED 

Doctors  in  dispensaries  and  hospitals  have  long 
been  troubled  by  the  plight  of  physically  han- 
dicapped patients.  Those  with  chronic  heart 
trouble  return  over  and  over  again  because  after 
discharge  they  have  gone  back  to  unsuitable  work. 
Others  suffering  from  accidents  that  have  necessi- 
tated amputation  of  a  limb,  from  industrial  disease 
such  as  lead  poisoning,  or  from  other  crippling 
disease,  may  have  had  the  needed  medical  or 
surgical  care,  but  may  find  self-support  apparently 
impossible.  In  the  first  annual  report  of  the  social 
work  at  the  Lakeside  Hospital  in  Cleveland,  Ohio, 
191 1,  Dr.  Warner  gives  the  story  of  a  mother  who 
had  come  to  the  hospital  seven  successive  times 
for  treatment  of  a  recurring  valvular  trouble  of  the 
heart.  The  265  days'  treatment  cost  the  hospital 
$586.  Her  breakdowns  were  due  to  repeated  over- 
work. 

With  the  advent  of  the  hospital  social  worker 
an  opportunity  for  the  solution  of  this  perplexing 
87 


SOCIAL   WORK    IN    HOSPITALS 

problem  of  employment  seemed  at  hand.  Yet, 
though  every  hospital  social  worker  has  recognized 
the  medical-social  tangle  that  the  handicapped 
patient  presents,  with  but  few  exceptions  her  plans 
for  these  "industrial  misfits"  have  been  unsatis- 
factory. She  has  found  herself  involved  in  a  com- 
plex of  elements  that  were  not  only  industrial, 
but  also -physical  and  psychological.  The  general 
employment  bureaus  have  proved  inadequate  to 
deal  with  the  special  problem  of  the  handicapped. 
The  Bureau  for  the  Handicapped,  established  in 
1908  in  connection  with  the  Charity  Organization 
Society  of  New  York,  but  discontinued  in  1912, 
was  the  only  one  in  the  country  that  had  under- 
taken as  its  special  function  to  find  jobs  for  those 
for  whom  the  other  bureaus  do  not  provide. 

A  few  schools  for  crippled  children  have  given 
them  industrial  training;  but  even  here  there  has 
been  discouragement  when  these  children  have 
tried  to  fit  themselves  into  the  taxing  industrial 
life  which  is  a  strain  on  even  the  most  vigorous 
children.  Some  states  have  met  the  problem  of 
employment  for  the  blind  by  the  establishment  of 
special  industries  such  as  rug  weaving,  but  this  is 
the  only  handicap  that  has  claimed  the  help  of  the 
state  towards  the  solution  of  the  question  of  em- 
ployment. 

The  number  of  handicapped  patients  in  the 
hospitals  has  increased  rather  than  diminished; 
their  need  of  work  is  unquestioned.  Their  physi- 
cal capacity  for  some  kinds  of  work  is  assured; 


MEDICAL-SOCIAL    PROBLEMS 

but  the  problem  as  a  whole  has  been  a  most  dis- 
couraging one. 

Since  November,  1911,  the  social  service  de- 
partment at  the  Massachusetts  General  Hospital 
has  had  the  good  fortune  to  have  the  services  of  a 
special  worker  through  affiliation  with  the  Com- 
mittee on  the  Handicapped  of  King's  Chapel, 
Boston.  In  this  capacity  Miss  Grace  I.  Harper 
has  made  a  preliminary  survey  of  several  indus- 
tries to  ascertain  the  significance  of  the  various 
processes  in  relation  to  the  position  and  the  strain 
on  the  worker.  She  has  also  made  a  study  of  the 
industrial,  social,  physical,  and  psychological  as- 
pects of  each  handicapped  patient  who  has  come 
to  her  attention  through  the  hospital  social  work- 
ers. With  careful  discrimination  she  has  success- 
fully placed  in  employment  many  who  would  other- 
wise have  still  been  economically  dependent,  and 
thus  increasingly  more  difficult  to  place  at  work. 
Miss  Harper  has  sought  to  discover  why  the  prob- 
lem of  employment  for  handicapped  people  has 
been  so  discouraging,  and  to  determine,  if  possible, 
some  way  of  helping  those  patients  whose  burden 
is  often  too  heavy  for  them  to  bear  alone,  and 
neglect  of  whom  means  not  only  unhappiness  to 
the  patient,  but  often  a  community  burden  as  well. 
It  is  expert  advice  and  long-continued  guidance 
that  they  need;  not  merely  someone  to  "find  a 
job"  for  them. 

A  girl  with  imperfect  eyesight  and  a  slight  par- 
alysis that  necessitated  a  sitting  position  at  work, 


SOCIAL   WORK    IN    HOSPITALS 

was  suitably  placed  at  a  shop,  covering  boxes.  A 
boy,  crippled  by  infantile  paralysis  to  the  extent  of 
badly  deformed  feet  but  slightly  affected  hand, 
was  found  to  have  an  ungratified  ambition  to  do 
some  kind  of  mechanical  work.  Counting  on  this 
ambition  to  help  overcome  many  difficulties  Miss 
Harper  made  it  possible  for  this  boy  to  learn 
watchmaking.  Although  he  was  absorbed  in  his 
work,  he  suggested  stopping  for  a  little  while  dur- 
ing the  coldest  weather.  His  mother  thought  it 
was  too  hard  for  him  to  go  back  and  forth  to  his 
work.  He  was  persuaded,  however,  not  to  humor 
himself  and  now  he  is  glad  that  he  persisted.  He 
has  already  surpassed  the  average  student  and 
will  soon  be  prepared  to  support  himself. 

Although  this  department  is  still  considered  an 
experiment,  Miss  Harper,  in  the  course  of  her 
struggles  with  the  complexities  of  each  patient's 
difficulties,  has  added  much  to  the  better  under- 
standing of  the  handicapped  patient.  There  has 
been  from  the  start  an  attempt  to  discriminate 
carefully  between  the  handicapped  and  the  inca- 
pacitated, i.  e.,  those  unfit  for  any  remunerative 
work.  The  desire  has  been  to  concentrate  on  se- 
curing employment  for  the  physically  handicapped. 
The  discrimination  was  to  be  made  on  the  ground 
of  physical  condition. 

The  following  instance  will  show  that  there  are 
other  elements  besides  physical  conditions  that 
may  lead  to  incapacitation: 


MEDICAL-SOCIAL    PROBLEMS 

Mr.  Behrens,  a  German  of  forty-six,  was  brought  to 
the  attention  of  the  department  because  his  funds  were 
nearly  exhausted  and  he  was  "in  need  of  light  work." 
He  had  an  infectious  disease  of  the  joints  that  left 
him  slightly  lame  and  with  hands  somewhat  crippled. 
He  had  not  had  steady  work  since  the  development  of 
this  disease  some  six  or  seven  years  before.  Inquiry 
revealed  the  fact  that  this  patient  had  been  a  valued 
employe  in  a  Young  Men's  Christian  Association,  where 
he  had  proved  himself  efficient  and  "honorable"  in  the 
capacity  of  attendant  at  the  gymnasium.  Both  he 
and  his  wife  had  been  employed  there  for  several  years. 
In  1910  she  had  become  insane  and  been  placed  in  an 
institution.  A  lodge  and  a  German  society  had  aided 
from  time  to  time  and  in  1911  had  sent  the  patient  back 
to  Germany  where  they  expected  him  to  remain.  In 
a  few  months,  however,  he  became  restless  and  returned 
to  America.  The  societies  again  aided  and  attempted 
repeatedly  to  secure  light  work  for  him.  When  posi- 
tions were  found  he  failed  to  keep  them. 

At  the  time  the  patient  was  brought  to  the  attention 
of  the  Committee  on  the  Handicapped  he  was  pro- 
nounced by  the  physicians  as  physically  fit  for  work 
that  would  not  necessitate  heavy  lifting.  The  pa- 
tient having  expressed  a  desire  for  janitor's  work  and 
also  a  wish  to  leave  the  city,  an  opportunity  was  se- 
cured for  him  in  New  Hampshire.  After  some  hesita- 
tion he  promised  to  go  on  a  definite  train  and  try  the 
work.  When  the  date  arrived  he  came  to  say  that  he 
guessed  he  would  not  go  to  New  Hampshire  as  he  had 
heard  of  a  possible  job  as  superintendent  of  a  club 
house  .where  he  might  be  in  charge  of  the  repairs,  the 
cleaning,  and  the  bowling  alleys.  Anyway,  "maybe 

9' 


SOCIAL   WORK    IN    HOSPITALS 

he  might  not  be  able  to  do  the  work  in  New  Hamp- 
shire." 

Several  other  attempts  were  made  to  place  this  pa- 
tient, but  at  last,  at  his  own  suggestion,  he  went  to 
the  almshouse.  Here  was  a  man  who  had  at  one  time 
been  ambitious  and  energetic,  but  through  prolonged 
idleness  and  semi-invalidism  had  lost  the  habit  of  ap- 
plication. 

Miss  Harper  feels  that  the  handicapped  patient 
almost  invariably  presents  a  mental  element  more 
or  less  like  that  of  the  invalid.  Whether  this  ele- 
ment is  due  to  the  shock  of  the  disease  or  accident, 
or  to  the  family's  prolonged  petting  of  the  patient, 
or  to  the  out-of-work  habit,  is  a  question.  It 
seems,  however,  that  successful  work  with  handi- 
capped patients  is  possible  only  when  each  patient 
is  considered  individually  and  careful  attention 
is  given  to  the  traits  and  tendencies  discovered. 
It  becomes  a  task,  not  only  of  finding  suitable 
work,  but  also  of  facing  a  process  of  re-education 
with  each  patient. 

George  Jellife,  a  boy  of  sixteen,  was  referred  to  the 
Committee  on  the  Handicapped  in  June,  1912,  by  the 
principal  of  a  school  for  crippled  children.  She  stated: 
"The  boy's  mother  is  going  to  live  near  Concord,  New 
Hampshire,  and  it  seems  best  for  George  to  leave  Bos- 
ton when  school  closes  and  get  employment  near  her." 
At  the  age  of  twelve  George  had  suffered  from  infantile 
paralysis.  His  legs  were  now  in  irons  and  he  used 
two  crutches.  The  principal  of  the  school  reported, 
"he  possesses  application,  perseverance,  and  willing- 
92 


MEDICAL-SOCIAL    PROBLEMS 

ness;  character  not  very  strong;  loves  appreciation; 
is  kind-hearted  and  frank,  honest  and  truthful."  The 
instructor  in  printing  reported  that  George  did  very 
well  for  the  time  spent  at  typesetting.  "He  can  set 
straight  copy  and  would  improve  with  practice;  has 
not  much  imagination  when  reading  handwriting  if  it 
is  scribbled  the  way  so  much  manuscript  is.  He  could 
feed  a  hand  press  easily  by  leaning  against  the  shelf  in 
front — many  people  lean  on  the  shelf,  anyway.  He  has 
endurance  and  strength  for  seated  work,  but  must  have 
room  for  his  legs  to  extend  straight  out  when  at  the 
bench.  He  can  also  manage  very  well  on  a  stool  at 
the  typesetting  case." 

Miss  Harper  talked  with  the  boy  and  found  him 
bright  and  eager  to  get  a  start.  He  was  advised  to 
wear  long  trousers  which  would  conceal  the  irons, 
thus  making  him  less  conspicuous.  His  plan  was  to 
visit  uncles  in  New  Hampshire  after  school  had  closed, 
and  to  be  in  readiness  to  respond  to  a  call  from  Miss 
Harper  at  any  time.  Miss  Harper  told  him  he  would 
probably  not  hear  for  a  week  or  ten  days  and  in  the 
meantime  should  look  around  and  see  what  he  could 
find  for  himself.  (This  was  to  let  him  realize  the  dif- 
ficulty in  securing  work.)  After  much  inquiry  a  letter 
came  from  a  printer  in  New  Hampshire  saying,  "A 
keen,  ambitious  boy  is  just  the  kind  we  are  looking 
for, — one  who  cares  for  something  more  than  six  o'clock 
and  pay  day."  They  thought  he  might  be  useful  in 
the  label  department  if  he  could  sit  on  a  stool  and  feed 
press,  or  stand  a  little, — enough  to  make  corrections 
and  changes  in  the  forms.  They  would  first  want  to 
see  and  talk  with  the  boy,  however,  and  would  be  glad 
of  more  information  about  his  condition. 

93 


SOCIAL   WORK    IN    HOSPITALS 

George  had  made  several  applications  for  work,  but 
was  repeatedly  unsuccessful.  When  word  came  that 
an  opportunity  was  open  to  him,  he  was  duly  apprecia- 
tive. He  was  personally  conducted  to  the  town,  his 
boarding  place  arranged  for,  and  the  employer  seen. 
When  the  time  came  for  the  worker  to  depart,  George's 
courage  was  fast  leaving  and  he  inquired  about  the  re- 
turning trains.  He  was  persuaded  to  stick  it  out,  how- 
ever, and  by  heroic  effort  on  his  part  and  continued 
interest  on  the  part  of  the  worker  he  stuck  to  it  for  a 
month.  At  the  end  of  that  time  he  asked  permission 
to  return  to  the  city  to  attend  a  ball  game.  When  he 
appeared  he  was  reminded  of  the  employer's  first  let- 
ter stating  that  he  wanted  a  boy  who  wanted  work 
more  than  play.  He  went  back  with  a  new  determina- 
tion to  remember  that  he  was  now  a  man  and  must 
make  good.  Late  reports  show  that  he  is  doing  so. 

The  recognition  of  the  importance  of  the  mental 
element  in  patients  who  are  physically  handi- 
capped has  related  this  subject  very  closely  to 
work  as  a  therapeutic  measure  for  the  neurotic. 
Dr.  Herbert  J.  Hall,  of  Marblehead,  Massachu- 
setts, has  given  several  years'  thoughtful  study  to 
the  application  of  this  principle,  and  to  search  for 
the  kinds  of  work  that  lend  themselves  most  suit- 
ably to  treatment  of  nervous  patients.  He  says:* 
"Manual  work,  used  as  a  remedy,  aims  to  intro- 
duce a  new  and  objective  interest,  gradually  forc- 
ing its  adoption  and  increasing  its  prominence  until 

*Hall,  Herbert  J.,  M.D.:  Manual  Work  in  the  Treatment  of 
Functional  Nervous  Diseases.  Read  in  the  Section  on  Nervous  and 
Mental  Diseases  of  the  American  Medical  Association,  June,  1910. 

94 


MEDICAL-SOCIAL    PROBLEMS 

the  mental  and  physical  habits  of  the  patient  are 
grouped  about  this  wholesome  center,  rather  than 
about  the  old  standard  of  illness  and  complexity. 
It  is  found  experimentally  that  this  plan  frequently 
does  represent  so  radical  a  change  that  some  at 
least  of  the  troublesome  nervous  symptoms  which 
may  have  become  quite  dependent  on  the  old  order 
drop  out  of  sight.  Manual  work  as  a  remedy,  if 
it  is  appropriately  and  wisely  used,  may  also,  in 
the  functional  derangements,  go  far  toward  bring- 
ing about  a  state  of  self-forgetfulness,  which  if 
attained  has  often  in  itself  meant  a  virtual  cure." 
Dr.  Hall  sees  clearly  that  while  satisfactory  em- 
ployment is  an  effectual  form  of  treatment  for 
patients  who  have  become  subjects  for  the  neurol- 
ogist, it  also  has  a  distinct  value  as  a  preventive 
measure.  Hospitals  that  care  for  the  chronically 
sick  or  for  patients  who  must  have  prolonged  rest, 
as  in  many  orthopedic  conditions,  are  sorely  in 
need  of  wholesome  occupation.  The  long  hours 
of  idleness  and  tedium,  especially  in  people  who 
have  not  had  the  opportunity  to  develop  resources 
within  themselves,  often  result  in  the  development 
of  a  habit  of  mind  that  does  not  readily  adjust 
itself  to  consistent  employment  when  the  patient 
is  again  able  to  work.  This  attitude  has  been  well 
described  as  a  condition  of  relaxation  of  "the  moral 
backbone,"  for  which  the  patient  is  not  necessarily 
responsible.  The  hospital  social  worker  sees  these 
after-effects.  To  her  we  must  look  for  the 
evidence  that  will  make  the  hospitals  more  con- 
95 


SOCIAL   WORK    IN    HOSPITALS 

scious  of  the  necessity  for  eliminating  this  demoral- 
izing by-product  of  medical  treatment. 

MEDICAL  ADVICE  TO  SOCIAL  AGENCIES 

As  non-medical  social  workers  dealing  with  indi- 
viduals in  distress  have  become  increasingly  con- 
scious of  the  significance  of  physical  conditions, 
they  have  more  and  more  sought  the  advice  and 
aid  of  physicians  and  hospitals.  Information  as 
to  the  physical  state  of  the  patients  is  found  to  be 
an  important  element  in  the  formulation  of  almost 
every  plan  for  aid.  The  mere  report  of  the  diag- 
nosis has  little  value  since  it  is  often  not  under- 
stood and  the  prognosis  is  usually  lacking.  Hence, 
social  workers  outside  of  hospitals  who  realize  the 
importance  of  understanding  something  of  physi- 
cal conditions,  have  welcomed  the  hospital  social 
worker  as  an  interpreter. 

Many  hospital  social  service  departments  now 
feel  the  importance  of  their  service  as  interpreters 
between  the  agencies  dealing  with  the  social  as- 
pects of  the  individual  problem  and  the  medical 
institution  to  which  the  patient  has  been  sent  for 
advice  on  the  physical  side.  Through  one  social 
service  department  many  children  who  have  come 
to  the  juvenile  court  are  sent  to  a  dispensary  for 
physical  and  mental  examination  before  the  judge 
decides  what  action  shall  be  taken  in  regard  to 
their  misdemeanor.  In  another  instance,  agencies 
dealing  with  children,  and  those  concerned  es- 
pecially with  family  problems,  make  a  practice  of 
96 


MEDICAL-SOCIAL    PROBLEMS 

having  a  physical  examination  whenever  this  is 
indicated.  In  several  social  service  departments 
blanks*  have  been  printed  for  these  cases  to  be 
"  steered."  These  blanks  are  placed  in  the  hands  of 
the  social  agencies  which  frequently  send  patients 
for  medical  examination  and  advice.  The  hospi- 
tal social  worker  is  thus  gradually  interpreting,  to 
the  social  workers  outside,  the  kind  of  social  facts 
that  it  is  necessary  for  them  to  know. 

Mr.  Mann,  single,  forty  years  of  age,  was  sent  by  a 
town  authority  to  a  dispensary  through  a  social  service 
department  with  request  for  a  report  on  the  man's 
physical  condition.  Mr.  Mann  presented  a  note  saying 
that  he  had  been  a  resident  of  —  -  for  many 

years;  that  he  was  intemperate;  that  he  had  from 
time  to  time  been  an  inmate  of  the  town  almshouse; 
and  that  at  present  he  was  destitute.  He  now  com- 
plained of  pain  in  his  back.  The  doctor  in  the  clinic 
found  Mr.  Mann  suffering  from  an  "old  Pott's  Dis- 
ease." The  report  as  given  by  the  doctor  and  inter- 
preted to  the  town  agent  was  somewhat  as  follows: 

Diagnosis,  Pott's  disease  (tuberculosis  of  the  spine) ; 
back  needs  proper  support,  (i)  No  treatment  will  re- 
sult in  increased  pain  and  contracted  chest  and  the 
possible  development  of  tuberculosis  of  lungs.  (2)  A 
plaster  jacket,  which  would  cost  about  $3.00,  would 
give  relief  from  pain  but  prohibit  work,  and  probably 
mean  almshouse  care.  (3)  A  leather  jacket  would 
cost  about  $15.  Would  relieve  pain  and  make  it 
possible  for  the  patient  to  work,  although  he  will  prob- 
ably never  be  well. 

*  See  Appendix,  pp.  222,  223. 
7  97 


SOCIAL   WORK    IN    HOSPITALS 

The  leather  jacket  was  later  ordered  and  paid  for  by 
the  town. 

The  following  case  shows  how  patients  sent  for 
physical  examination  often  need  to  return  for 
treatment ;  also  that  the  medical-social  worker  in 
the  dispensary  and  the  social  agency  outside  can 
work  together  to  carry  out  the  treatment  pre- 
scribed by  the  doctors.  The  patients  were  Mrs. 
Poole  and  her  six  children:  Mary  and  Hattie, 
twins  age  ten;  John,  age  eight;  Andrew,  age 
seven;  Delia,  age  five;  and  Frank,  age  three. 

Agency's  Statement.  Mrs.  Poole  wishes  to  have  her 
eyes  examined;  thinks  she  has  rheumatism.  She  is 
a  widow  with  six  children.  The  Associated  Charities 
hopes  to  get  a  pension  for  the  family,  but  must  first 
have  statement  as  to  their  physical  condition. 

Doctor's  Statement.  Mrs.  Poole  examined  in  the  medi- 
cal clinic,  February  27;  has  a  pulse  of  120.  The  doctor 
makes  diagnosis  of  endocarditis  (heart  disease)  and 
constipation.  Medicine  is  given.  Mrs.  Poole  is  to 
return  to  the  clinic  in  a  week.  She  is  referred  to  the 
Eye  Clinic,  where  they  report  defective  vision.  Drops 
ordered.  To  return  in  a  week.  The  worker,  Miss 
Hedley,  reports  the  above  by  telephone  to  the  Associ- 
ated Charities  who  will  see  that  she  comes  in  at  the 
proper  time.  Miss  H.  explains  that  the  doctor  is  not 
sure  as  to  the  origin  of  the  heart  trouble,  but  may  be 
aggravated  by  excessive  tea  drinking,  care,  work,  and 
worry.  Is  told  that  the  patient  should  not  do  washings 
or  carry  coal. 

Mar.  23,  Mrs.  Poole  brings  John  and  Andrew  to  the 
98 


MEDICAL-SOCIAL    PROBLEMS 

Children's  Clinic.  John  is  found  to  have  obstetrical 
paralysis  of  the  right  arm  and  should  have  gymnastic 
exercises  on  Tuesdays  and  Saturdays.  (This  will  give 
the  unaffected  muscles  a  chance  to  develop.)  They  will 
probably  operate  on  his  arm  later, — transplantation 
of  muscles.  There  is  a  suspicion  of  tuberculosis  in 
Andrew  and  an  out-of-door  school  is  recommended. 
Will  have  the  blood  tested  for  evidence  of  tuberculo- 
sis (v.  Pirquet  test).  Miss  Hedley  gives  the  above 
report  by  telephone,  also  sends  a  written  summary 
of  the  physical  condition  of  mother  and  children  to  the 
Associated  Charities. 

Three  days  later  John  comes  in  for  gymnastic  ex- 
ercises and  Frank  for  examination.  No  definite  diag- 
nosis is  made  for  Frank.  He  should  be  under  obser- 
vation. The  trouble  may  be  auto-intoxication  due 
to  gastro-intestinal  indigestion,  or  may  be  appendi- 
citis or  cyclic  vomiting.  Miss  Hedley  reports  to 
Associated  Charities  and  asks  if  they  can  arrange  to 
have  someone  bring  John  in  for  his  exercises  on  Tues- 
days and  Saturdays;  also  asks  for  a  summary  of  family 
situation.  A  friendly  visitor  is  secured  who  brings 
the  children  regularly. 

Mrs.  Poole  comes  in  April  4  with  Hattie,  Mary,  and 
Delia.  The  children  are  examined  in  the  Children's 
Clinic.  The  physical  examinations  are  negative  except 
for  carious  teeth.  They  come  in  from  time  to  time 
for  their  dental  treatment.  Mrs.  Poole  reports  John  and 
Frank  are  at  home,  both  feverish  and  vomiting.  She 
is  examined  in  the  Medical  Clinic  and  found  much 
better;  her  pulse  has  dropped  from  120  to  98;  she  is 
given  a  tonic,  and  is  to  come  to  the  Eye  Clinic  next  day. 
Miss  Hedley  makes  the  above  report  to  the  Associated 

99 


SOCIAL   WORK    IN    HOSPITALS 

Charities;  asks  to  have  dispensary  doctor  visit  John 
and  Frank,  also  to  have  home  conditions  made  easier 
for  Mrs.  Poole. 

In  a  few  days  the  Associated  Charities  telephones 
that  arrangements  have  been  made  so  that  Mrs.  Poole 
need  not  bring  the  coal  upstairs  and  that  the  housework 
has  been  made  easier  for  her. 

April  23d,  Mrs.  Poole's  glasses  are  delivered  to  her. 
She  now  goes  to  the  Dental  Clinic  where  they  advise 
having  all  the  teeth  extracted.  Later,  the  District 
Secretary  of  the  Associated  Charities  comes  to  the 
Dispensary  to  talk  over  the  family  situation.  Reports 
that  Associated  Charities  had  been  paying  the  family 
$2.50  a  week  but  was  to  discontinue  that  until  $100 
which  Mrs.  Poole  had  received  from  her  husband's 
employer  had  been  used  up.  A  plan  was  being  consid- 
ered to  have  Mrs.  Poole  go  to  work  as  stenographer 
and  telephone  operator,  which  work  she  did  before 
her  marriage.  The  mother  and  six  children  live  with 
an  aunt  in  a  nice  apartment  near  the  park.  They  have 
no  rent  to  pay  nor  fuel  to  buy.  The  District  Secretary 
also  asks  advice  as  to  sending  John  to  the  school  for 
crippled  children. 

The  next  day  Mrs.  Poole  has  all  her  teeth  removed 
under  ether.  Miss  Hedley  telephones  this  to  the  As- 
sociated Charities  with  the  plan  to  have  John  and  An- 
drew go  to  a  vacation  house  for  May  and  June  under 
the  direction  of  the  doctor  in  the  Children's  Clinic. 
They  are  to  have  their  teeth  attended  to  first.  The 
plan  is  agreed  upon,  the  Associated  Charities  and 
mother  each  to  pay  $i  a  week.  When  the  children 
have  been  out  in  the  country  a  week,  the  visiting  doctor 


100 


MEDICAL-SOCIAL    PROBLEMS 

sends  John  into  Dispensary  for  operation  to  remove 
adenoids  and  tonsils. 

During  this  time,  Mrs.  Poole  complains  of  severe 
backache.  She  is  referred  from  the  Medical  to  the 
Gynaecological  Clinic.  The  diagnosis  is  Lacerated 
Cervix  and  Perineum;  rectocele  (the  ordinary  result 
of  childbearing  and  poor  obstetrics).  Condition  found 
to  be  sufficient  to  account  for  severe  pain.  May 
advise  operation  later.  This  reported  to  Associated 
Charities. 

Mrs.  Poole  comes  in  after  six  weeks.  Reports  that 
children  were  very  well  when  they  first  came  back 
from  country.  John  is  all  right  now,  but  Andrew  has 
been  coughing  a  good  deal  and  spat  a  little  blood  the 
other  day. 

Andrew  comes  in  for  examination  the  next  day  and 
the  doctor  says  he  is  undoubtedly  tuberculous.  The 
visitor  will  arrange  to  have  him  placed  out,  as  it  would 
not  be  possible  for  him  to  have  the  proper  care  at 
home.  A  week  later  the  District  Secretary  reports 
that  the  whole  family  has  gone  on  a  country  outing  for 
two  weeks. 

Early  in  October,  word  comes  from  the  Associated 
Charities  that  Andrew  is  to  be  in  New  Hampshire 
for  the  winter,  where  he  will  receive  proper  care.  They 
are  now  giving  Mrs.  Poole  a  pension  of  $7.00  a  week. 

Mrs.  Poole  brings  John  to  the  Orthopedic  Clinic, 
where  massage  is  prescribed  for  two  to  three  months  in 
muscles  of  his  arm. 

Mrs.  Poole  goes  to  the  Gynaecological  Clinic.  Doc- 
tor says  an  operation  will  be  necessary.  She  is  also 
seen  in  the  Dental  Room,  where  they  report  her  gums 
in  good  condition  for  artificial  teeth. 

101 


SOCIAL   WORK    IN    HOSPITALS 

This  story  is  not  yet  ended.  It  illustrates  con- 
ditions in  only  one  of  the  families,  nearly  over- 
powered by  burdens,  physical  and  financial,  that 
societies  for  organizing  charity,  all  over  the 
country,  are  helping  to  their  feet.  Social  workers 
in  dispensaries  and  hospitals  can  often  help  to 
eliminate  physical  handicaps  and  so  to  aid  in  the 
constructive  plans  which  other  workers  are  striv- 
ing to  carry  out  for  the  families  under  their  care. 

Aside  from  the  types  of  problems  presented  in 
these  chapters  there  are  many  others  continually 
crowding  upon  hospital  social  workers.  Two  very 
important  and  ever  present  medical-social  prob- 
lems in  hospitals  and  dispensaries  that  have  not 
been  considered  are  alcoholism  and  venereal  dis- 
ease. Many  physicians  and  hospital  social  workers 
believe  that  the  medical  approach  to  these  social 
diseases  offers  the  most  hopeful  opportunity  for 
successful  social  treatment  and  for  study  of  social 
causes.  They  also  recognize  that  in  the  effort  to 
study  and  to  treat  these  diseases,  physicians  and 
social  workers  are  essentially  interdependent. 
Very  little  has  so  far  been  accomplished  in  this 
interesting  but  undeveloped  field  of  medical-social 
service.  A  large  amount  of  personal  work  with 
both  these  groups  of  patients,  very  special  quali- 
fications for  such  personal  work,  and  more  men 
workers  who  are  prepared  to  undertake  such  social 
service,  are  all  factors  that  are  essential  before  we 
can  hope  for  any  measure  of  success. 


MEDICAL-SOCIAL    PROBLEMS 

A  preliminary  survey  of  the  cases  of  gonorrhea 
attending  the  Boston  Dispensary  over  a  period  of 
about  six  months  showed  that  out  of  a  group  of 
450  patients,  215,  or  47.8  per  cent,  came  only 
once  for  treatment  and  70,  or  15.6  per  cent,  came 
only  twice,  making  a  total  of  63.4  per  cent  who 
came  but  once  or  twice.  The  ineffectiveness  of 
such  treatment  is  apparent,  but  the  social  bearing 
of  this  ineffective  treatment  and  the  lost  oppor- 
tunity for  some  constructive  social  work  can  only 
be  imagined.*  Out  of  another  group  of  507  men 
with  gonorrhea  attending  the  Boston  Dispensary, 
128  were  under  twenty  years  of  age,  and  of  these 
75  per  cent  were  first  infections.  It  would  be 
interesting  and  valuable  to  know  to  what  extent 
ignorance,  lack  of  proper  recreation,  or  poor  home 
conditions,  lay  in  the  background  of  this  situ- 
ation. Surely  there  are  opportunities  here  for 
some  educational  work  as  well  as  for  study  of 
causes. 

Another  group  of  patients,  children  with  vulvo- 
vaginitis,  has  been  a  matter  of  serious  concern  to 
both  physicians  and  hospital  social  workers.  It  is 
evident  that  the  search  for  the  source  of  infection 
of  these  little  girls  is  most  important,  and  that 
the  most  patient,  thoughtful  educational  work  is 
necessary.  But  we  are  far  from  having  determined 
how  that  educational  work  should  be  carried  on. 
At  the  present  time  we  can  agree  only  on  the  im- 

*  Davis,  Michael  M.,  Jr.:  The  Efficiency  of  Out-Patient  Work. 
Journal  of  the  American  Medical  Association,  Nov.  9,  1912,  Vol. 
LIX,  pp.  1689-1691. 

103 


SOCIAL   WORK    IN    HOSPITALS 

portance  of    knowing    the    extent    and    possible 
sources  of  these  infections.* 

The  great  number  of  patients  needing  instruc- 
tion in  hygiene  or  in  carrying  out  treatment  form 
a  large  group  for  whom  the  hospital  social  worker 
is  a  teacher.  A  little  girl  of  thirteen  was  once  sent 
to  the  department  by  the  assistant  superintendent 
of  a  hospital  with  the  word  that  considerable 
free  medicine  had  been  given  to  her  and  her  sister. 
"Are  they  making  good  use  of  it?"  A  study  of 
this  family  of  eleven  revealed  the  fact  that  they 
had  all  been  coming  to  the  hospital  for  nearly 
three  years,  especially  for  treatment  of  scabies; 
the  hospital  had  granted  free  admission,  free  medi- 
cine, and  free  hospital  care,  and  had  spent  in  all 
$255.27.1  At  the  time  the  girl  was  referred  to  a 
social  service  department,  all  the  eleven  members 
of  the  family  had  scabies, — a  highly  unsatisfactory 
return  on  an  investment  of  $255.  After  one  week's 
treatment  of  the  whole  family  under  supervision 
by  a  hospital  social  worker,  the  disease  was  cured, 
and  for  two  years  and  a  half  has  not  returned. 

In  all  the  work  that  falls  to  the  lot  of  the  hospi- 
tal social  worker  she  must  meet  prejudices,  ig- 
norance, and  misunderstandings.  The  prejudices, 
because  of  their  complexities,  must  often  be  re- 
spected; in  so  far  as  they  are  matters  of  ignorance 
they  may  sometimes  be  overcome.  So  the  hos- 

*  Smith,  Richard    M.,  M.D.:  Vulvovaginitis  in  Children.     Read 
at  meeting  of  the  American  Medical  Association,  June,  1913. 
t  See  Appendix,  p.  224. 

104 


MEDICAL-SOCIAL  PROBLEMS 

pital  social  worker  becomes  a  teacher  and  an  in- 
terpreter, and  the  basis  of  her  teaching  and  her 
plans  for  social  treatment  of  the  patient  always 
must  be  a  knowledge  of  the  social  background  of 
the  patient's  physical  condition. 


105 


CHAPTER  VII 
BASIS  OF  TREATMENT 

HOSPITAL  social  service  depends  for  its 
justification,  not  on  the  wave  of  popular 
interest  which  it  has  recently  aroused,  not 
on  the  gratitude  of  patients  for  kindly  help,  but 
rather  on  the  efficiency  of  the  social  work  that  is 
done.  The  gratitude  of  those  whom  we  aid  is  not 
in  itself  a  criterion  of  good  work,  although  to  many 
it  has  justified  the  indiscriminate  doling  of  alms. 
Many  a  man  in  the  medical  profession,  ignorant 
and  ill  prepared  for  his  work,  is  able  to  inspire  such 
loyalty  and  gratitude  in  his  patients  that  his  mal- 
practice seems  almost  like  a  benefit  bestowed. 

While  poor  social  work  may  not  have  these  par- 
ticular dangers,  social  workers  must  beware  of 
similar  pitfalls.  Human  kindness  should  always 
characterize  social  work,  but  human  kindness 
alone  cannot  solve  our  tangled  social  problems; 
nor  can  it  minister,  unaided,  to  the  body  or  the 
mind  diseased.  As  I  see  it,  the  social  worker's 
function  does  not  lie  especially  in  a  sympathy  with 
human  nature  in  immediate  distress  of  mind 
and  body.  Physician  and  nurse  appreciate  these 
phases  of  the  patient's  condition.  Rather  does 
1 06 


BASIS    OF   TREATMENT 

the  social  worker's  function  lie  in  an  enlarged  un- 
derstanding of  any  psychic  or  social  conditions 
which  may  lie  at  the  root  of  the  patient's  distress 
of  mind  and  body.  Faulty  character,  diseased 
community  life,  and  unwholesome  human  rela- 
tions are  the  field  of  her  study  and  constructive 
effort.  Her  knowledge  of  these  factors,  added  to 
the  doctor's  knowledge  of  physical  factors,  gives  a 
broad  basis  for  action  both  medical  and  social. 
To  make  her  contribution  valuable,  the  medical- 
social  worker  must  bring  to  her  task  the  best  that 
the  profession  of  social  work  has  to  offer.  Ani- 
mated by  an  eager  sympathy  with  suffering,  the 
social  worker  no  less  than  the  doctor  or  the  nurse 
is  in  search  for  truth.  But  her  field  is  different, 
and  the  value  of  her  contribution  depends  on  this 
very  fact  of  its  being  drawn  from  a  different  field. 

Several  factors  determine  the  quality  of  the 
social  work  in  a  medical  institution.  The  skill  of 
the  worker  is  of  primary  importance.  Next,  the 
kind  of  help  that  she  receives  from  the  doctors 
and  from  the  hospital  authorities  largely  decides 
the  scope  and  success  of  her  activity.  Other  de- 
termining factors  are  the  number  of  patients  in 
proportion  to  the  staff  of  workers  and  the  supply 
of  helpful  community  resources.  Last,  but  not 
least,  is  the  willing  co-operation  of  the  patient 
himself.  Co-operation  must  be  more  than  respon- 
siveness, but  responsiveness  marks  the  first  step 
towards  a  co-operative  relationship. 

The  patient  usually  has  a  trusting  confidence  in 
107 


SOCIAL   WORK    IN    HOSPITALS 

the  ability  of  the  hospital  to  relieve  his  physical 
distress,  else  he  would  not  seek  its  help.  He  is 
responsive  to  anyone  who  approaches  him  on  the 
basis  of  his  physical  need.  The  social  worker  in 
the  hospital  has,  then,  the  great  advantage  of  an 
easy  approach  to  the  patient,  and  thus  a  frank 
discussion  of  his  problems  is  made  possible.  Both 
patient  and  social  worker  tacitly  recognize  his 
physical  difficulties  as  the  final  factor  putting  him 
out  of  joint  with  his  environment.  He  appeals  to 
the  hospital  for  help,  conscious  of  no  responsibility 
for  his  condition.  As  a  result,  he  suffers  none  of 
that  loss  of  self-respect  involved  in  asking  material 
aid.  When  application  is  made  to  a  relief  society, 
though  more  fundamental  causes  may  lie  back  of 
the  obvious  need,  the  basis  on  which  the  applicant 
approaches  the  society  is  that  of  a  failure  in  self- 
support.  The  patient  who  applies  to  the  charity 
hospital  may  also  feel  a  sensitiveness  in  not  being 
able  to  pay  for  his  care.  This  feeling  is,  however, 
more  often  due  to  belief  that  he  would  receive 
better  care  if  he  paid  for  it.  The  physical  need 
alone  carries  with  it  little  of  the  sense  of  failure 
that  accompanies  economic  need. 

At  present  physical  illness  is  looked  upon  as  one 
of  the  inevitable  experiences  common  to  all  of  us. 
When  we  realize,  as  we  may  some  day,  that  sick- 
ness is  the  usual  attendant  of  ignorance,  neglect, 
or  immorality,  either  on  the  part  of  the  individual 
or  of  the  community,  our  point  of  view  may  change 
and  we  may  cease  to  be  so  complacent  about  our 
108 


BASIS    OF    TREATMENT 

diseases.  The  time  may  come  when  tuberculosis, 
infant  mortality,  industrial  accidents,  diseases  of 
occupation,  many  forms  of  blindness,  and  diseases 
resulting  from  fatigue  will  be  found  in  our  hospitals 
only  to  our  shame.  But  for  the  present  the  pa- 
tient comes  as  a  victim,  not  of  poverty,  stupidity, 
or  vice,  but  merely  of  the  "ills  that  flesh  is  heir  to." 
On  this  basis  the  patient  meets  the  physician,  the 
nurse,  and  the  social  worker,  and  his  natural  re- 
sponsiveness is  of  incalculable  aid  to  them.  To 
the  physician  and  the  nurse,  his  relationship  is 
largely  one  of  dependence.  The  duty  of  the  social 
worker  is  to  help  him  to  help  himself  whenever 
that  is  possible.  His  responsive  obedience  to  the 
medical  workers  must  be  developed  into  a  spirit 
of  co-operation  if  the  social  worker  is  to  build  con- 
structively on  the  foundation  of  the  medical  help 
the  patient  has  received. 

To  establish  this  co-operative  relation,  the  social 
worker  should  have  all  the  factors  in  the  case  well 
in  hand.  She  should  have  first  of  all  an  intelligent 
appreciation  of  the  patient's  physical  condition, 
not  merely  the  name  of  his  malady.  This  is  al- 
ways her  important  first  step  in  understanding  the 
patient's  needs  as  well  as  her  basis  for  common 
action  with  the  doctor.  Next,  it  is  her  responsi- 
bility to  see  how  far  that  physical  condition  is 
complicated  by  elements  other  than  those  which 
the  doctor  can  detect  by  his  professional  methods. 

In  her  search  for  these  elements,  which  form  the 
background  of  the  patient's  difficulties,  the  hos- 
109 


SOCIAL   WORK    IN    HOSPITALS 

pital  social  worker  must  consider  not  only  the 
patient's  physical  state  as  presented  by  the  doctor, 
but  also  his  mental,  emotional,  and  social  states 
as  she  can  deduce  them  from  the  various  sources  of 
information  open  to  her.  Her  interpretation  of 
the  patient's  physical  condition  should  include  the 
doctor's  diagnosis,  and  especially  his  prognosis  and 
plan  of  treatment.  The  medical-social  worker  is 
usually  granted  the  privilege  of  seeing  the  medical 
records,  but  she  depends  far  more  on  the  doctor's 
interpretation  of  the  record  as  he  discusses  the 
case  with  her.  Most  medical  records  are  so  meager 
that  one  must,  if  possible,  secure  additional  facts 
from  the  physician  while  the  condition  of  the 
patient  is  still  fresh  in  his  mind. 

This  inquiry  also  gives  the  social  worker  an  op- 
portunity to  pass  on  to  the  physician  social  facts 
that  are  of  importance  because  his  plan  of  treat- 
ment must  sometimes  be  modified  in  the  light  of 
social  conditions.  But  the  social  worker  must 
keep  the  doctor's  plan  definitely  in  mind  as  the 
ideal  formed  before  the  hampering  social  compli- 
cations were  considered.  In  other  words,  when 
a  compromise  is  necessary,  the  worker  must  re- 
member that  an  ideal  has  been  perforce  abandoned, 
not  another  standard  of  treatment  established. 
Take  the  case  of  a  girl  debilitated  by  working  in  a 
factory:  the  doctor  has  prescribed  rest,  variety  of 
food,  and  outdoor  life;  but  she  may  be  compelled 
to  receive  a  plan  of  treatment  involving,  instead, 
a  better  understanding  of  the  laws  of  hygiene,  or  a 


BASIS   OF   TREATMENT 

change  of  occupation,  because  any  attempt  to 
give  her  a  radical  change  of  environment  could 
only  be  temporary.  Thus,  the  social  worker  must 
at  times  be  willing  to  accept  a  second  best  plan 
for  her  patient,  but  she  must  not  lose  sight  of  the 
fact  that  it  is  second  best  when  considered  from 
the_physical side  alonet 

The  psychological  elements,  which  the  social 
worker  must  consider,  are  of  fundamental  impor- 
tance. They  include  the  patient's  character,  his 
temperament,  his  reaction  to  the  experience  of 
illness,  and  his  attitude  toward  those  endeavoring 
to  help  him.  To  those  who  know  people  in  physi- 
cal distress  it  is  a  commonplace  that  the  psycho- 
logical may  in  so  far  color  the  physical  condition 
as  to  make  the  same  disease  in  two  individuals 
seem  due  to  diiferent  infections.  This  is  equally 
true  in  economic  conditions.  Poverty  may  take 
the  vitality  out  of  one  man,  may  find  another 
philosophically  acquiescent,  and  spur  still  another 
to  renewed  efforts.  Prosperity  produces  a  similar 
variety  of  results. 

In  the  interplay  of  the  physical,  economic,  and 
psychological  factors,  the  psychological  domin- 
ates; hence  the  understanding  of  this  subtle  re- 
action of  human  nature  to  circumstance  should  en- 
gage the  most  thoughtful  efforts  of  the  medical- 
social  worker.  To  secure  a  knowledge  of  the  pa- 
tient's character  involves  piecing  together  facts 
from  many  sources :  from  his  looks,  manners,  dress 
and  bearing;  from  what  he  says;  from  the  atti- 
iii 


SOCIAL   WORK    IN    HOSPITALS 

tude  of  his  mind  towards  the  difficulties  of  his 
life;  from  all  that  can  be  learned  about  the  time  of 
"his  high  water  mark"  in  the  social  world;  and 
from  his  own  hope  or  despair  as  to  the  future.  A 
knowledge  of  these  factors  is  often  of  much  more 
importance  to  the  plan  for  the  patient's  future 
than  the  knowledge  of  his  previous  economic  con- 
dition. The  worker's  understanding  of  these  as- 
pects of  character  depends  on  her  power  to  see 
meaning  in  the  facts  which  she  collects  by  the 
conventional  methods  of  history  taking. 

The  first  talk  with  the  patient  may  disclose  very 
few  social  facts.  It  may  be  that  the  only  essential 
element  in  the  first  interview  is  to  secure  the  pa- 
tient's confidence,  to  establish  a  friendly  relation- 
ship, and  to  explain  to  him  her  own  function  as 
related  to  that  of  the  doctor  and  nurse.  In  our 
work  with  nervous  patients  or  girls  in  moral 
danger,  this  is  particularly  true.  In  their  eager- 
ness to  get  at  social  facts,  social  workers  sometimes 
expect  to  enjoy  the  confidence  of  the  patient  be- 
fore it  has  been  gained.  Usually,  however,  the 
medical-social  worker  has  little  difficulty  in  taking 
this  first  step.  The  plans  of  an  outside  social 
worker  must  sometimes  be  explained  to  the  pa- 
tient; but  the  patient  readily  understands  the 
hospital  social  worker's  function,  because  his  need 
of  her  is  always  closely  related  to  his  immediate 
physical  difficulty. 

There  is  a  skeleton  of  information  about  the 
patient  which  it  is  necessary  to  secure  if  we  are  to 

112 


BASIS    OF   TREATMENT 

have  even  a  superficial  knowledge  of  him:  his  age, 
his  residence,  his  nationality,  his  part  in  the  fam- 
ily group,  his  occupation,  something  of  his  eco- 
nomic situation.  These  facts  can  be  ascertained 
through  direct  questions;  they  give  a  background 
for  further  details  and  sometimes  offer  clues  to  the 
causes  of  his  difficulties.  I  recall  a  patient  sent 
to  a  social  service  department  in  order  to  ascertain 
the  possible  source  of  his  lead  poisoning.  The 
man  gave  his  occupation  as  shoemaking.  The 
social  worker  noticed  a  peculiar  habitual  move- 
ment of  his  mouth.  Following  this  clue,  she  dis- 
covered that  for  several  years  he  had  held  in  his 
mouth  while  at  work  the  little  pegs  used  in  his 
trade  and  thus  absorbed  the  metal  into  his  system. 

After  securing  the  first  necessary  facts  it  is  well 
for  the  social  worker  to  ask  as  few  leading  ques- 
tions as  possible;  rather  she  should  have  the  pa- 
tient tell  his  story  as  fully  as  his  time  and  her 
own  allows,  guiding  him  sometimes  and  selecting 
from  his  disclosures  those  facts  which  bear  particu- 
larly on  the  social  aspect  of  the  case.  The  art  of  a 
first  interview  involves  questioning  and  listening 
with  a  plan  in  mind,  but  with  a  perpetual  readiness 
to  change  that  plan.  Direct  questions  tend  to 
bring  out  only  the  facts  which  the  worker  is  looking 
for  and  may  leave  hidden  some  of  those  unexpected 
sources  of  anxiety  and  difficulty  that  are  the  real 
source  of  the  patient's  trouble. 

A  woman  sent  by  the  doctor  to  a  hospital  social 
worker  to  secure  her  medicine  free,  was  found  on 

8  1 13 


SOCIAL   WORK    IN    HOSPITALS 

investigation  to  be  struggling  under  a  burden  too 
heavy  for  her  to  bear.  Since  she  and  her  three 
children  had  been  deserted  three  years  before  she 
had  supported  them  by  day  work.  A  son  was 
found  to  be  desperately  ill  with  appendicitis  at 
the  city  hospital.  Another  child,  concerning 
whom  the  mother  was  greatly  worried,  was  found 
to  have  incipient  tuberculosis.  Had  the  hospital 
generously  donated  the  tonic  which  the  doctor 
ordered  for  this  mother,  and  given  no  considera- 
tion to  her  anxieties  for  her  children,  the  tonic 
would  have  profited  her  little. 

If  a  patient's  social  problem  is  uncomplicated,  a 
superficial  knowledge  of  the  facts  may  be  all  that 
is  needed.  It  is  impossible,  however,  to  tell  before- 
hand how  far  an  investigation  must  go.  When 
Lincoln  Steffens  began  to  investigate  the  shame  of 
the  cities,  he  soon  found  that  he  must  follow  the 
trail  to  the  state  capital  and  ultimately  to  Wash- 
ington itself.  With  the  doctor's  diagnosis  and  plan 
of  medical  treatment  at  hand,  one  must  realize  that 
the  aim  of  the  social  investigation  has  not  been 
attained  until  an  effective  plan  of  medical-social 
treatment  can  be  formulated  to  meet  the  needs  of 
the  patient.  On  the  other  hand,  it  takes  as  much 
discrimination  to  know  when  to  stop  an  inves- 
tigation as  when  to  go  on  with  it.  The  only  sure 
way  to  test  any  decision  based  on  such  superficial 
knowledge  is  to  follow  up  the  case  and  see  whether 
the  result  has  been  what  the  worker  anticipated. 
If  a  patient  has  flatfoot,  but  is  otherwise  in  good 
114 


BASIS    OF    TREATMENT 

health  and  able  by  an  easily  arranged  plan  to  pay 
for  her  plates,  no  further  activity  on  the  part  of 
the  social  worker  may  be  necessary.  On  the  other 
hand,  a  little  further  understanding  of  the  patient 
may  indicate  the  necessity  for  her  changing  her 
work  to  one  less  trying  to  the  feet.  From  the 
comparatively  fortunate  state  of  this  patient,  there 
are  all  gradations  to  the  desperate  condition  of 
the  sufferer  for  whom  at  present  nothing  can  be 
done  either  medically  or  socially  because  with  our 
present  limitations  no  amount  of  social  knowledge, 
investigation,  or  work  can  make  treatment  ef- 
fective. Thus,  most  social  workers  feel  a  hope- 
lessness about  confirmed  alcoholics  and  drug 
habitues. 

Investigation  of  the  social  side  of  the  patient's 
life  is  tabooed  by  many  who  do  not  understand  its 
motives  or  values.  Often  the  doctors  themselves 
are  impatient  of  social  investigation.  There  are 
those  who,  blind  to  its  real  significance,  regard  the 
questioning  of  the  patient  as  an  impertinence. 
But  impertinence  implies  a  base  motive.  If 
either  the  doctor  or  the  hospital  social  worker  has 
a  plan  in  view  into  which  the  answers  to  the  ques- 
tions fit  as  a  piece  into  a  puzzle  picture,  and  the 
plan  is  for  the  good  of  the  patient,  there  is  no 
possibility  of  impertinence.  The  social  worker 
must  be  ready  to  explain  to  herself  or  the  patient 
the  reason  for  each  question  she  asks.  There  can 
then  be  no  misunderstanding  on  either  side. 
During  the  questioning,  facts  of  character  come 
115 


SOCIAL  WORK    IN    HOSPITALS 

out  on  both  sides,  facts  which  help  in  later  rela- 
tionships. The  hospital  social  worker  who  has 
learned  something  of  the  art  of  dealing  with  people 
will  never  allow  her  questionings  to  become  stereo- 
typed. The  information  which  she  seeks  in  each 
case  will  bear  close  relationship  to  the  need  which 
seems  at  the  time  to  be  urgent. 

A  visit  to  the  patient's  home  is  often  essential  to 
a  better  understanding  of  the  social  status  and 
living  conditions  of  the  patient.  It  also  serves  to 
illuminate  the  patient's  trouble  from  the  family's 
point  of  view,  which  is  sometimes  much  saner  and 
usually  somewhat  different  from  that  of  the  pa- 
tient. To  carry  out  an  effectual  plan  usually 
requires  the  family's  help,  and  at  times  a  plan  is 
greatly  modified  in  the  light  of  a  home  visit.  The 
following  case  illustrates  the  value  of  learning  the 
home  conditions: 

A  nervous  little  girl  of  fifteen  was  once  referred  by 
a  neurologist  to  a  social  service  department  with  the 
request  that  she  be  sent  to  a  class  for  stammerers.  A 
teacher  of  articulation  had  told  the  neurologist  that 
he  would  gladly  take  some  patients  in  his  Saturday 
afternoon  class.  Realizing  the  social  and  economic 
handicap  of  her  affliction,  she  stammered  out  her  ap- 
preciation of  this  opportunity,  which  was  all  the  better 
because  it  would  not  interfere  with  her  working  time. 
A  talk  with  the  patient  and  a  visit  to  the  home  revealed 
the  fact  that  this  anaemic,  nervous  girl  was  working 
nine  hours  a  day  in  a  net  and  twine  factory,  where  her 
fingers  were  flying  every  moment ;  that  daily  she  walked 
116 


BASIS    OF    TREATMENT 

a  mile  to  her  work  and  a  mile  back;  and  that  at  the 
end  of  the  day  she  returned  to  cold  rooms  and  to 
entirely  inadequate  food,  improperly  prepared.  The 
mother,  a  prematurely  old  widow  with  two  daughters, 
worked  all  day  in  a  factory, — though  she  was  entirely 
unfit  for  it, — and  had  no  strength  after  her  work  to  at- 
tend to  the  physical  needs  of  her  family.  The  total 
income  of  the  family  was  eight  dollars  a  week.  Through 
the  efforts  of  the  social  service  department,  the  church 
and  a  relief  agency  were  called  upon  to  supplement 
the  income  and  the  patient  was  sent  away  for  several 
months'  rest.  After  a  year  of  watchful  oversight  the 
social  worker  succeeded  in  bringing  the  patient  to  the 
condition  where  she  was  fit  to  have  the  training  in 
speech. 

The  patient's  family  is  usually  more  ready  to 
co-operate  when  the  trouble  is  physical  than  when 
it  is  economic.  The  thought  of  pain  and  possible 
death  rouses  a  sympathy  which  is  keener  and 
quicker  in  its  action  than  that  produced  by  the 
thought  of  poverty  and  unemployment.  The 
worker  should  make  the  most  of  this  psychological 
situation  both  for  securing  the  information  neces- 
sary to  perfect  her  plan  and  for  interesting  the 
family  in  the  success  of  the  plan. 

If  the  patient  has  a  suggestion  of  his  own,  that 
should  be  first  considered  even  if  it  is  an  impossible 
one,  for  he  is  more  likely  to  give  his  co-operation 
to  a  modification  of  his  own  idea  than  to  a  per- 
fectly new  one.  In  fact,  the  final  plan  must  be  a 
composite  adjustment  of  three  points  of  view, — 
117 


SOCIAL   WORK    IN    HOSPITALS 

those  of  the  doctor,  the  social  worker,  and  the 
patient. 

Patience  and  tactful  persistence  are  often  neces- 
sary to  bring  about  the  adjustment  of  these  three 
points  of  view.  A  young  man  came  to  a  dispen- 
sary for  treatment  of  enlarged  glands  in  his  neck. 
On  examination  it  was  found  that  these  glands 
were  tuberculous  and  that  there  was  an  incipient 
tuberculosis  of  the  lungs.  Immediate  sanatorium 
care  was  advised  by  the  physician,  and  the  medical- 
social  worker  was  asked  to  make  the  necessary 
arrangements  for  his  admission.  The  patient  and 
his  family  had  a  fear  of  hospitals  which  the  worker 
could  not  overcome.  Failing  this,  she  kept  watch 
of  the  patient  at  home,  instructing  him  in  hygiene 
and  urging  him  from  time  to  time  to  accept  sana- 
torium care.  After  a  few  weeks  an  abscess  de- 
veloped in  the  glands  of  his  neck.  The  patient 
then  consented  to  enter  a  general  hospital  for  a 
few  days  to  have  the  abscess  treated.  This  ex- 
perience dispelled  his  fear  of  institutions,  and  he 
consented  to  go  to  the  tuberculosis  sanatorium 
immediately  after  his  discharge  from  the  general 
hospital.  Thus  the  original  plan,  although  be- 
lated, was  carried  out,  with  the  most  sincere  grati- 
tude of  the  patient  and  an  appreciation  of  his 
former  misjudgment. 

In  many  cases  the  interview  with  the  patient 

at  the  hospital  and  one  home  visit  suffice  to  secure 

the  needed  information.    Success  is  marked  by  our 

ability  to  formulate  an  effective  plan  of  treatment 

118 


BASIS    OF   TREATMENT 

without  further  study.  By  the  time  the  investi- 
gation has  gone  as  far  as  this  the  worker  should 
at  least  begin  to  see  which  personal  tie  the 
patient  regards  most  tenderly  and  which  influence 
can  be  strengthened  to  help  solve  his  present  dif- 
ficulty. These  aids  may  be  found  in  the  family, 
the  church,  the  employer,  the  secret  society,  or  a 
friend, — in  fact,  in  any  of  the  natural  ties.  These 
factors  in  the  individual's  life  are  not  only  many 
times  essential  to  effective  treatment,  but  through 
them  information  may  be  secured  for  the  founda- 
tion of  the  plan  of  social  treatment. 

The  sources  of  information  about  any  patient 
then  are  varied  and  can  be  completely  utilized  only 
by  the  social  worker  who  knows  how  to  follow 
clues  and  to  discriminate  between  those  that  are 
important  and  those  that  are  unimportant.  Many 
a  bulky  social  record  has  missed  the  essential 
points. 

A  tentative  social  treatment  based  only  on 
superficial  study  is  sometimes  necessary  in  view 
of  the  urgency  of  the  patient's  condition.  In 
medical  work  the  patient  with  a  hemorrhage  is 
treated  immediately  to  stop  the  bleeding  before 
further  examination  is  attempted.  It  is  recog- 
nized, however,  that  hemorrhage  is  a  symptom  and 
not  a  diagnosis.  Back  of  the  hemorrhage  may  be 
tuberculosis  of  the  lungs,  or  an  internal  injury  that 
must  be  treated  before  the  patient  can  possibly 
recover.  Just  so  the  emergency  outfit  of  clothing 
that  may  have  to  be  supplied  to  the  patient  is 
119 


SOCIAL  WORK    IN    HOSPITALS 

only  the  treatment  of  a  symptom.  Patients  who 
need  material  aid  almost  invariably  need  more 
than  that,  and  the  hospital  social  worker  should 
not  be  content  with  emergency  social  service,  ex- 
cept in  the  very  rare  cases  when  emergency  service 
is  really  all  that  is  needed.  A  sick  person  in  need 
of  material  things  is  peculiarly  appealing.  A  gro- 
cery order,  like  a  dose  of  morphine,  may  ease  the 
present  situation.  But  the  medical-social  worker 
must  remember  that  such  relief  can  rarely  prevent 
a  recurrence  of  the  need.  The  cause  of  the  need 
should  be  the  object  of  her  search,  for  not  until  the 
cause  is  known  can  any  constructive  plan  be  de- 
veloped. 

Social  investigation,  like  medical  examination, 
may  be  either  simple  or  involved,  local  or  systemic. 
The  surgeon  who  is  called  upon  to  treat  a  broken 
arm  does  not  first  take  the  patient's  family  history 
before  setting  the  bone.  If  there  are  no  further 
indications  of  difficulties,  the  bone  is  set  and  the 
patient  departs.  If  the  patient  presents  obscure 
symptoms  which  necessitate  more  extended  ex- 
amination, the  diagnosis  may  have  to  be  deferred 
until  by  the  X-rays,  by  laboratory  tests,  or  by  a 
period  of  observation  the  true  condition  is  re- 
vealed. While  minor  symptoms  may  be  treated 
from  the  first,  an  intelligent  plan  must  be  delayed 
until  the  physician  has  determined  the  diagnosis. 
In  the  same  way  the  skilled  social  worker  must  be 
able  to  distinguish  between  these  two  degrees  of 
involvement  of  the  patient  in  social  difficulties, 


BASIS    OF    TREATMENT 

before  she  can  know  how  extensive  to  make  the 
examination  or  what  plan  of  treatment  to  follow. 

I  remember  a  patient  sent  to  a  social  service  de- 
partment by  the  admitting  physician  of  the  dis- 
pensary. He  had  admitted  the  patient  later  than 
the  hospital  rules  prescribe,  after  she  had  told  him 
that  she  had  walked  from  her  home.  He  asked  the 
social  workers  to  arrange  for  her  fares  to  and  from 
the  hospital  during  the  time  she  needed  treatment 
for  some  local  disease.  The  social  worker  had  a 
talk  with  the  patient  and  visited  the  home,  where 
a  friend  also  was  seen.  Here  she  discovered  that 
the  family  was  in  no  financial  need,  as  the  husband 
was  earning  $18  a  week  and  provided  well  for  his 
wife  and  children.  The  woman  stated  that  she 
had  been  "very  nervous  for  several  years,"  a  story 
which  her  friend  corroborated.  The  patient  was 
eager  to  talk  of  her  symptoms  and  troubles,  and 
finally  it  came  out  that  she  had  a  fixed  idea  against 
riding  in  street  cars  and  had  not  been  in  one  for 
several  years, — not  even  on  the  day  after  the  super- 
intendent so  kindly  gave  her  her  carfare.  Thus 
was  disclosed  a  mental  condition  far  more  serious 
than  her  local  trouble,  and  more  difficult  to  cure. 
To  give  her  carfare  was  aiming  wide  of  the  mark. 

We  must  not  give  the  doctor  or  patient  any  sur- 
mises or  guesses  which  can  by  any  possibility  be 
construed  as  facts.  Facts  can  be  secured  only  by 
an  intelligent  search,  by  balancing  sources  of  in- 
formation, and  by  a  critical  attitude  toward  preju- 
diced statements.  Many  things  tend  to  blind  us 


SOCIAL  WORK   IN    HOSPITALS 

in  our  search  for  the  facts  in  social  investigation. 
First,  the  lack  of  experience  on  which  to  base  sound 
judgment.  Second,  our  own  emotional  response. 
We  are  inclined  to  inject  our  own  feeling  into  a 
judgment  of  the  patient's  distress  of  mind,  and  to 
formulate  an  opinion  without  getting  a  true  per- 
ception of  his  condition.  But  the  sick  patient's 
point  of  view  is  often  warped,  as  also  may  be  the 
point  of  view  of  his  family.  That  is  one  reason 
why  he  needs  the  social  worker  as  an  adviser.  If 
she  is  to  do  her  greatest  service  she  must  keep  her 
judgment  balanced  and  sane. 

One  young  boy  of  sixteen  was  more  in  need  of 
the  social  worker  than  he  realized.  His  legs  had 
become  quite  helpless  through  an  attack  of  polio- 
myelitis that  had  not  been  skilfully  treated.  The 
best  the  doctors  could  do  for  him,  when  he  came 
to  the  attention  of  a  well-known  dispensary,  was 
to  prescribe  braces,  so  that  he  could  walk  with 
crutches.  Two  or  three  years  of  sickness  and  idle- 
ness, and  an  indulgent  family,  had  left  him  with 
little  ambition.  The  social  worker  had  not  only 
to  teach  this  boy  patiently  and  persistently  to  keep 
at  the  job  she  secured  for  him,  but  also  to  strengthen 
the  morale  of  his  family  so  as  to  prevent  them 
from  giving  him  entire  support.  She  taught  both 
the  patient  and  the  family  that  happiness  was  to 
be  found  in  work,  not  in  idleness,  and  that  the  best 
protection  for  this  boy  was  an  ability  to  care  for 
himself. 

Failure  to  take  into  account  all  the  important 


BASIS   OF   TREATMENT 

psychological  elements  involved  in  such  a  situa- 
tion as  this  "would  make  social  treatment  ineffec- 
tive. Thus,  only  after  seeking  for  the  many-sided 
truth,  whether  it  is  a  matter  of  finances,  hygiene, 
psychology,  or  past  experience,  can  a  sound  plan 
of  action  be  developed.  Often  the  truth  when 
found  reveals  little  promise  for  effective  effort. 
Many  a  social  worker  has  spent  months  or  years 
of  fruitless  struggle  at  reconstruction  of  character, 
only  to  find  that  the  boy  or  girl  was  feeble  of  mind 
and  consequently  incapable  of  self-control.  If 
the  facts  had  been  known  earlier  much  energy, 
unjust  criticism,  and  disappointment  might  have 
been  saved. 

In  discussing  the  aim  of  the  medical-social 
worker's  investigation,  Dr.  Cabot  once  said  to  me, 
"  Patient  and  worker  can  rest  content  when — and 
only  when — they  have  done  either  what  is  efficient 
or  what  proves  that  efficiency  is  here  and  now 
impossible.  Miserable  uncertainty  and  fruitless 
effort  are  the  worst  of  the  miseries  to  harassed  social 
worker  and  to  struggling  patient.  Next  to  being 
cured  there  is  a  very  genuine  satisfaction  in  know- 
ing that  one  must  endure, — to  place  one's  fate  and 
find  a  foothold  somewhere,  even  in  defeat.  Def- 
initeness — after  exhaustive  study — is  the  one  thing 
all  patients  can  rightly  demand  and  all  workers 
rest  upon.  It  is  no  mean  support.  I  have  seen 
its  benefit  to  many.  It  sets  worker  and  patient 
free  to  think  clearly  about  something  or  someone 
else." 

123 


CHAPTER  VIII 
WORKING  TOGETHER 

THE  number  of  charities  or  social  agencies 
in  a  community  is  not  a  true  measure  of  its 
strength  for  social  good.  The  organization 
of  each  relief  society,  each  welfare  association,  and 
the  building  of  each  charitable  institution  or  social 
settlement  is  a  tangible  expression  of  philanthropic 
or  civic  interest;  but  their  existence  does  not  guar- 
antee their  efficiency  or  the  community's  need 
of  them.  In  certain  cities  there  are  charitable 
agencies  initiated  through  the  efforts  of  small 
groups  of  people  who,  knowing  of  individuals  in 
distress  and  interpreting  that  distress  as  evidence 
of  a  community  need,  have  sought  to  meet  it  by 
organized  effort.  Other  agencies  are  maintained 
by  legacies  left  by  philanthropically  inclined  but 
socially  ignorant  persons.  In  this  way  there  de- 
velops a  crop  of  more  or  less  heterogeneous,  un- 
related charities.  A  city  may  be  oversupplied 
with  orphan  asylums,  "rescue  homes,"  or  day 
nurseries,  while  at  the  same  time  crying  needs, 
such  as  playgrounds  and  amusement  centers,  re- 
main unmet. 

In  some  cities  the  uncontrolled  multiplication  of 
124 


WORKING   TOGETHER 

agencies  for  relief  has  resulted  in  much  duplication 
of  function.  While  it  is  reasonable  to  assume  that 
no  expression  of  human  interest  is  wholly  wasted, 
we  must  grant  that  much  strength  is  lost  if  there  are 
no  unity  of  aim  and  no  harmony  among  the  charit- 
able forces  in  a  community.  The  hospital  social 
worker,  while  having  special  functions  of  her  own, 
needs  much  assistance  from  various  social  agencies. 
She  cannot  build  up  within  the  hospital  a  well 
organized  associated  charities,  a  relief  society,  a 
factory  inspection  department,  or  a  department 
of  school  nursing.  All  large  cities  are  supporting 
such  agencies  as  these.  She  can  do  her  part 
toward  creating  a  sense  of  relatedness  among  the 
agencies  that  she  uses.  For  instance,  she  may  see 
fit  to  introduce  the  truant  officer  to  the  clergyman 
in  an  attempt  to  relieve  the  anxiety  of  a  father  who 
is  having  difficulty  in  keeping  his  boy  in  school 
while  the  mother  is  in  the  hospital.  In  her  struggle 
with  vexing  questions  the  hospital  social  worker 
must  work  shoulder  to  shoulder  with  other  social 
workers.*  Through  this  experience  she  comes  to 
feel  that  spirit  of  social  service  which  humbly 
recognizes  the  smallness  of  individual  effort  in 
relation  to  the  greatness  of  human  need  and  is  in- 
spired by  the  high  enthusiasm  that  arises  when 
many  work  together  for  social  righteousness.  The 
real  measure  of  the  community's  strength  for 

*  See  Byington,  Margaret  F. :  What  Social  Workers  should  Know 
about  Their  Own  Community.  Published  by  the  Charity  Organiza- 
tion Department  of  the  Russell  Sage  Foundation. 

125 


SOCIAL  WORK    IN    HOSPITALS 

good,  then,  lies  not  in  the  number  and  variety  of 
its  institutions,  not  alone  in  the  personality  or  en- 
thusiasm of  its  social  workers,  but  also  in  the 
effective  joining  of  their  forces.  The  effectiveness 
of  such  co-operative  effort  is  the  principle  recog- 
nized in  campaigns  for  better  housing,  anti-tu- 
berculosis crusades,  and  all  the  social-educational 
programs. 

Hospital  social  service  aims  to  bring  to  the  pa- 
tient's aid  the  particular  community  resources 
which  will  most  effectively  assure  his  return  to 
health.  Hence  the  social  worker  must  know  what 
these  resources  are  and  how  to  use  them  judici- 
ously. She  can  no  more  afford  to  be  ignorant  of 
these  resources  than  a  doctor  can  afford  to  be  ig- 
norant of  the  remedies  used  in  the  treatment  of 
disease.  They  are  her  social  pharmacopoeia.  Nor 
must  she  be  too  dependent  upon  any  one  social 
remedy  as  a  cure-all;  there  are  quacks  in  the  treat- 
ment of  social  disease  as  there  are  in  medicine. 
The  diet  order  and  convalescent  home  offer  ex- 
amples of  the  remedies  often  given  but  not  always 
adequate  to  the  need.  The  real  test  of  the  social 
worker's  skill  is  her  ability  to  diagnose  accurately 
the  social  conditions  of  the  patient,  to  prescribe 
intelligently,  and  to  find  the  means  to  carry  out 
effectively  the  treatment  best  suited  to  a  particu- 
lar social  condition.  The  tired  girl  may  need  not 
only  a  week  in  the  convalescent  home;  she  may 
need  to  be  taught  how  to  sleep  and  to  eat,  to  get 
proper  amusement,  or  to  bear  a  burden  of  sorrow. 
126 


WORKING   TOGETHER 

Sometimes  the  social  worker  in  prescribing 
social  treatment  must  depend  on  changing  the  en- 
vironment. Sometimes  the  remedy  must  be  com- 
pounded out  of  the  forces  within  the  individual  so 
as  to  help  the  patient  to  help  himself;  thus  it  is  with 
the  neurasthenic  patient.  Still  another  patient 
may  need  the  aid  of  several  agencies  in  the  com- 
munity that  exist  to  alleviate  his  special  forms  of 
distress.  The  social  worker  must  then  construct 
a  plan  that  skilfully  combines  these  forces.  She 
must  have  the  kind  of  skill  shown  by  the  physician 
whose  carefully  balanced  prescription  combines 
several  drugs  in  such  proportions  as  to  be  much 
more  helpful  than  any  single  remedy. 

The  hospital  social  worker  has  a  special  oppor- 
tunity to  understand  and  encourage  co-operation. 
She  hopes  to  see  the  hospital  become  a  more  con- 
sciously social  institution  than  it  is  at  present, 
but  neither  she  nor  any  enthusiastic  promoter  of 
hospital  social  service  wishes  to  have  the  hospital 
lose  its  characteristic  function  as  a  technical  in- 
stitution for  the  physical  care  of  the  sick.  The 
hospital  cannot  and  should  not  so  enlarge  its  func- 
tions as  to  be  able  to  meet  all  the  needs  of  those 
whose  physical  well-being  it  seeks  to  promote. 
Recognizing  this,  we  should  not  attempt  to  mul- 
tiply the  special  activities  within  the  hospital  it- 
self, but  should  turn  to  the  community  to  discover 
and  use  the  many  agencies  already  developed  to 
deal  with  social  wrongs  and  misfortunes. 


127 


SOCIAL   WORK    IN    HOSPITALS 

The  conviction  in  the  minds  of  many,  that  the 
social  problems  of  hospital  patients  are  unique, 
is  soon  dispelled  by  a  real  understanding  of  the 
functions  and  activities  of  the  other  agencies. 
Many  of  the  problems  that  come  to  the  medical- 
social  worker  are  human  tangles  involving  numer- 
ous other  elements  besides  poverty.  Fatigue,  moral 
dangers,  alcoholism,  and  incurable  disease  are 
some  of  the  evils  that  attack  mankind  irrespective 
of  economic  condition.  Because  they  are  often 
further  complicated  by  poverty  they  are  familiar 
to  charity  organization  and  relief  societies.  The 
great  majority  of  patients  with  medical-social 
needs,  especially  those  whose  needs  are  most  dire, 
belong  to  the  same  group  of  people  who  come  to 
the  attention  of  other  social  agencies.  While  the 
hospital  population  represents  a  great  variety  of 
economic  levels,  it  would  seem  that  the  large  bulk 
of  people  frequenting  our  charitable  hospitals  are 
near  the  poverty  line,  many  of  them  victims  of 
the  social  distress  with  which  charity  organization 
societies,  visiting  nurses,  settlements,  and  relief 
societies  have  long  struggled. 

No  thorough  survey  of  the  industrial,  social, 
and  financial  standing  of  hospital  patients  has 
ever  been  made.  There  are  in  our  hospitals,  no 
doubt,  some  whose  disease  is  the  result  of  wretched 
social  conditions;  others  whose  disease  may  prove 
to  be  the  road  by  which  they  will  enter  the  field 
of  wretchedness  and  dependence;  and  others  still 
128 


WORKING   TOGETHER 

who  by  a  narrow  margin  will  again  become  self- 
supporting  when  they  recover. 

A  step  towards  an  enlightening  analysis  of  the 
patients  coming  to  a  charitable  dispensary  was 
taken  in  the  winter  of  191 1-12  at  the  Boston  Dis- 
pensary. The  study  covered  only  1 16  patients, — 
the  total  number  of  "new"  patients  applying  at 
the  hospital  on  two  days.  It  is,  however,  valu- 
able, first  because  it  proves  that  hospitals  have  the 
opportunity  for  social  service  to  people  on  a  va- 
riety of  economic  levels,  and  also  because  it  exem- 
plifies a  method  for  determining  roughly  the  finan- 
cial standing  of  those  who  apply  for  free  dispensary 
treatment.  Among  116  patients  the  investiga- 
tors found  the  following  economic  conditions, 
classified  according  to  the  groups  defined  in  Booth's 
"  Life  and  Labor  of  the  People  of  London." 

"Casual  Laborers 8 

Unskilled  labor,  low  paid,  irregular  work   .        .        .21 
Unskilled  labor,  low  paid,  regular  work      .        .        .36 

Total  of  unskilled  and  casual  labor.        ...  65 

Skilled  labor,  irregular  work 13 

Skilled  labor,  regular  work 19 

Total  of  skilled  labor 32 

Clerical  work 9 

Business  (managers  or  owners) 6 

Professional  occupation i 

Total  of  clerical  and  higher  grades  ....  16 

Total     •.-.-.-. 113 

Patients  living  in  an  institution 2 

Information  insufficient  for  grading    ....  i 

Grand  total 116 

9  129 


SOCIAL   WORK    IN    HOSPITALS 

"Thus,  56  per  cent  of  the  patients  are  in  the 
grades  of  unskilled  labor  or  below;  28  per  cent 
in  the  class  of  skilled  labor;  and  14  per  cent  are 
in  the  clerical  or  business  groups. 

"It  would  be  an  error  to  draw  from  these  per- 
centages any  direct  inference  as  to  the  proportion 
of  patients  who  could  have  paid  a  private  phy- 
sician. Eligibility  for  dispensary  treatment  can- 
not safely  be  determined  from  economic  grade 
alone.  The  members  of  the  family  of  a  clerk 
earning  $18  a  week,  with  six  children,  may  be 
much  more  suitable  subjects  for  'medical  charity' 
than  an  unmarried  laborer  earning  $12."* 

It  will  be  seen  that  to  meet  the  needs  of  these 
various  groups  of  people  various  social  forces  are 
required.  For  that  reason  the  hospital  social 
worker  must  be  resourceful  and  imaginative,  ready 
to  grasp  her  opportunity  to  adapt  social  service 
to  many  people  with  many  kinds  of  needs. 

A  catalogue  of  the  city's  resources  is  an  invalu- 
able help  in  effective  co-operation.  Many  cities 
have  charity  directories  in  which  the  various 
agencies  are  grouped  according  to  their  function, 
with  indexes,  cross  references,  and  annotations  to 
suggest  the  means  of  approach,  such  as  the  names 
of  the  executive  officer  and  the  office  hours.  The 
city  directory  with  its  wealth  of  information  con- 
cerning churches,  lodges,  and  business  organiza- 
tions, and  the  yearbooks  of  the  various  churches 

*  Davis,  Michael  M.,  Jr.;  Efficiency  Tests  of  Out-patient  Work. 
Boston  Medical  and  Surgical  Journal,  Vol.  CLXVI,  No.  25,  p.  917. 
130 


WORKING    TOGETHER 

are  also  most  helpful.  Of  the  smaller  towns  and 
cities  few  have  any  published  catalogue  of  their 
charitable  resources,  and  the  worker  is  dependent 
largely  on  the  accumulation  of  her  experience  for 
a  knowledge  of  the  agencies  in  the  community  that 
are  available  for  her. 

With  the  frequent  shifting  of  workers,  some  way 
of  preserving  the  accumulation  of  experience  is 
very  important.  A  simple  method  of  accumulat- 
ing valuable  information  about  the  community's 
resources  is  to  make  a  card  catalogue  of  such  re- 
sources as  do  not  appear  in  any  published  direc- 
tory. Such  information  can  be  carefully  classi- 
fied according  to  subject  and  location  so  that  it 
may  be  readily  accessible  for  future  use.  A  cata- 
logue of  this  character  should  contain  the  names 
of  lodges  and  benefit  societies,  their  officers  and 
addresses;  people  interested  in  special  nationali- 
ties,— for  instance,  Poles,  Italians,  Swedes;  special 
information  on  church  clubs,  charities,  and  funds. 
The  names  of  firms  and  notes  of  prices  for  outfits 
for  tubercular  patients — tents,  chairs,  sputum 
cups,  paper  napkins — should  be  secured;  the 
names  of  carpenters  who  will  build  outdoor  sleep- 
ing porches;  reliable  boarding  places  with  notes 
about  accommodations  and  prices;  the  names  of 
lawyers,  doctors,  and  interpreters  who  will  volun- 
teer their  services,  or  of  individuals  who  would 
give  time  and  personal  interest  to  patients  need- 
ing friendly  oversight  and  long  continued  super- 
vision. Such  a  catalogue  is  especially  valuable  to 


SOCIAL   WORK    IN    HOSPITALS 

those  social  workers  whose  field  covers  not  only 
the  city  in  which  the  hospital  is  located,  but  ex- 
tends over  into  the  suburbs. 

In  the  social  service  department  at  the  Massa- 
chusetts General  Hospital  some  500  "  resources  of 
suburban  towns"  have  been  accumulated  and 
tabulated  in  card  catalogue  form  during  seven 
years.  The  case  number  of  a  patient  helped  by 
any  one  of  these  persons  or  agencies  is  often  en- 
tered on  the  card,  so  that  reference  to  the  case 
record  will  give  more  details  about  the  quality  of 
help  secured.  It  has  been  found  necessary  to 
assign  to  one  person  the  task  of  keeping  this  cata- 
logue up  to  date. 

One  very  helpful  feature  of  such  a  catalogue  is 
in  presenting  conveniently  information  about  other 
hospitals.  Much  effort  is  saved  when,  by  consult- 
ing the  card  catalogue,  one  can  find  out  the  hospital 
resources  of  the  city,  both  private  and  public,  the 
types  of  cases  accepted,  the  scale  of  charges,  and 
the  quickest  way  to  get  patients  in.  Cross  refer- 
ence cards  indexing  the  special  groups  of  cases 
accepted,  as  cancer,  chronic  diseases,  and  tubercu- 
losis, are  also  useful. 

Both  public  and  private  agencies  are  to  be  found 
in  most  cities.  The  public  agencies  represent  the 
responsibilities  which  the  community  has  already 
accepted.  The  obligations  first  recognized  by  the 
state  are  those  for  protection  of  its  citizens  through 
prisons,  insane  asylums,  almshouses,  etc.  A 
gradually  enlarging  sense  of  civic  responsibility 
132 


WORKING    TOGETHER 

constantly  increases  the  number  and  variety  of 
public  agencies.  Most  cities  have  a  charitable 
and  correctional  group  of  public  institutions  which 
deal  with  the  economically  dependent  and  with 
those  whose  conditions,  moral  or  physical,  are  a 
menace  to  the  community.  Among  the  city  and 
state  agencies  most  used  by  the  hospital  social 
worker  are  hospitals,  almshouses,  institutions  for 
the  care  of  the  insane,  epileptic,  and  feeble-minded, 
sanatoria  for  the  tuberculous,  overseers  of  the  poor, 
boards  of  health,  tenement  house  and  factory  in- 
spectors, school  teachers,  physicians,  nurses,  city 
ambulances,  and  still  other  agencies  concerned 
with  the  sick  in  their  homes. 

Private  agencies  usually  originate  with  a  small 
group  of  persons  who  hope  to  demonstrate  whether 
or  not  the  value  of  their  activity  is  sufficient  to 
deserve  its  permanence  as  a  public  benefit  and  a 
public  charge.  Examples  of  such  effort  are  seen 
in  the  services  of  school  nurses,  anti-tuberculosis 
societies,  and  milk  stations.  Established  by  pri- 
vate initiative,  they  have  in  many  large  cities  been 
taken  up  as  legitimate  activities  of  the  city  govern- 
ment. 

Among  the  private  agencies  with  which  the 
hospital  social  worker  should  be  familiar  are  those 
for  material  relief;  those  dealing  with  needy  fami- 
lies— such  as  the  associated  charities  (or  charity 
organization  society)  and  Jewish  relief  societies; 
the  children's  agencies,  both  those  that  place  chil- 
dren in  foster  homes  and  those  that  supervise  the 
133 


SOCIAL   WORK    IN    HOSPITALS 

child  in  his  own  home;  the  societies  for  protection 
of  children  from  cruelty;  the  visiting  nurses,  school 
nurses,  teachers,  settlements,  churches,  lodges,  and 
benefit  societies;  and  the  many  religious  organiza- 
tions, such  as  the  Society  of  St.  Vincent  de  Paul 
and  the  King's  Daughters. 

Every  community  has  some  if  not  all  of  these 
agencies.  To  know  where  they  are  and  how  to 
work  with  them  is  one  of  the  hospital  social  work- 
er's first  qualifications.  In  a  large  city  it  is  very 
difficult  to  bring  all  the  complex  social  agencies 
into  friendly  team  work.  The  best  way  to  cut 
out  duplication  of  effort,  and  to  achieve  quick, 
efficient  service  to  the  needy  is  found  in  the  "con- 
fidential exchange"  of  information,  or  "charity 
clearing  house."*  Such  a  bureau  has  been  es- 
tablished in  several  cities.  The  oldest  exchange 
is  that  maintained  by  the  Associated  Charities 
in  Boston.  Eighty-seven  social  agencies  use  this 
exchange.  Its  machinery  is  simple  and  effective. 
The  names  and  addresses  of  all  persons  inquired 
about  are  arranged  in  a  card  catalogue,  with  a 
note  stating  what  agency  or  individual  is  interested 
in  that  particular  person  or  family.  Thus  this 
exchange  serves  not  as  a  bureau  of  detailed  in- 
formation concerning  any  individual  but  rather 
as  an  index  to  persons  who  are  under  the  care 
of  one  or  another  of  the  social  agencies  in  the 
city.  When  inquiry  is  made  by  telephone  or  mail 

*  See  Byington.  Margaret  F.:  The  Confidential  Exchange,  a  form 
of  Social  Co-operation.  Published  by  the  Charity  Organization  De- 
partment of  the  Russell  Sage  Foundation. 

•34 


WORKING   TOGETHER 

the  file  is  consulted.  If  the  name  of  the  person 
inquired  for  is  already  known  to  any  agency,  the 
person  inquiring  is  told  that  fact  alone.  Any  in- 
formation concerning  the  person  must  be  secured 
through  the  agency  or  individual  already  inter- 
ested. The  confidential  exchange  itself  gives  out 
no  information  other  than  this.  If  there  has  been 
no  previous  inquiry,  the  identifying  information 
and  the  name  of  the  agency  or  individual  inquiring 
are  filed  in  the  catalogue.  The  card  is  not  consulted 
unless  someone  else  becomes  charitably  interested. 

The  success  of  such  a  bureau  depends  upon  three 
conditions:  the  intelligent,  business-like  manage- 
ment of  the  bureau  by  those  in  charge;  the  strict- 
est sense  of  the  confidential  nature  of  all  infor- 
mation; and  the  intelligent  and  prompt  use  of 
the  information  secured  by  the  inquirer.  Despite 
careful  management  a  bureau  may  be  rendered 
useless  if  persons  inquiring  do  not  follow  the  clues 
given  them  through  the  exchange,  and  so  fail  to 
get  into  touch  with  other  persons  who  may  at  that 
very  time  be  actively  interested  in  the  same  pa- 
tient. 

The  following  illustration  shows  the  value  of 
the  confidential  exchange: 

A  patient  was  asked  to  come  to  the  out-patient  de- 
partment for  the  dressing  of  an  acute  abscess.  The 
surgeon  reported  to  the  social  service  department 
that  she  could  not  come  because  of  her  baby.  She  was 
a  Hebrew  and  spoke  almost  no  English.  The  social 
worker  immediately  telephoned  to  the  confidential 
'35 


SOCIAL   WORK    IN    HOSPITALS 

exchange  and  found  that  the  family  had  been  known 
to  several  social  agencies  for  many  years.  The  state 
had  charge  of  two  children,  a  children's  agency  had 
charge  of  an  infant  but  was  about  to  return  it,  and  a 
Hebrew  society  had  for  some  time  known  the  family. 
It  was  the  baby's  return  that  was  worrying  the  mother. 
The  father  was  anxious  to  care  for  his  family,  but  ig- 
norance of  the  English  language  and  lack  of  work  had 
forced  him  to  seek  assistance.  A  conference  of  those 
actually  interested  in  the  family  was  called.  The 
hospital  social  worker  reported  the  physical  needs  of 
the  woman.  The  children's  agency  decided  to  keep 
the  child  until  the  mother  was  fit  to  care  for  it.  The 
Hebrew  society  renewed  their  relations  with  the  family 
and  secured  work  for  the  man,  while  the  medical-social 
worker  kept  supervision  of  the  patient  until  she  was 
well. 

This  solution  of  a  complicated  family  situation 
took  very  little  of  the  hospital  social  worker's  time 
and  was  satisfactory  to  all  concerned.  A  second 
case  illustrates  the  waste  of  effort  due  to  absence 
of  registration. 

The  parents  of  a  very  troublesome  feeble-minded 
child  were  loath  to  send  him  to  an  institution.  After 
much  effort  on  the  part  of  the  hospital  social  worker 
they  were  persuaded  to  apply  for  the  child's  admission 
to  a  school  for  the  feeble-minded.  When  the  applica- 
tion went  in,  the  social  service  department  was  in- 
formed by  the  institution  that  another  application 
had  been  previously  filed  by  a  children's  agency. 
On  consulting  this  agency  it  was  found  that  it  had  gone 
136 


WORKING   TOGETHER 

through  the  same  struggle  to  persuade  the  parents  of 
the  wisdom  of  custodial  care.  The  parents  had  come 
to  the  hospital  in  the  hope  that  an  operation  could  be 
performed  which  would  cure  the  child  and  make  insti- 
tution care  unnecessary. 

A  contrast  is  shown  in  the  following  illustration: 

A  woman  came  to  the  hospital  in  urgent  need  of  im- 
mediate operation.  She  refused  to  enter  the  hospital 
because  she  did  not  know  what  would  become  of  her 
children.  On  inquiry  at  the  exchange  it  was  discovered 
that  the  family  was  known  to  the  Associated  Chari- 
ties. The  hospital  worker  telephoned  the  friendly 
visitor  who  had  known  the  family  for  a  long  time.  She 
eagerly  shouldered  the  responsibility  for  the  care  of 
the  children,  and  made  a  plan  for  the  husband  during 
the  wife's  absence.  Thus  relieved  of  her  anxiety,  the 
woman  entered  the  hospital.  The  hospital  social 
worker  kept  the  friendly  visitor  informed  of  the  wom- 
an's condition.  The  visitor  persuaded  her  to  continue 
her  convalescence  until  she  was  in  fit  condition  to  re- 
sume her  family  cares. 

To  those  who  have  used  the  confidential  ex- 
change for  many  years  it  becomes  an  expression 
of  true  co-operation.  It  not  only  says,  "Let  us 
know  if  anyone  is  already  interested  in  this  pa- 
tient," but  it  also  says,  "  I  am  interested  in  this 
patient  and  stand  ready  to  help."  Through  the 
operation  of  the  exchange,  social  workers  in  the 
community  are  continually  reminded  of  one  an- 
other's existence.  Where  no  such  exchange  exists, 
a  conscious  effort  is  often  necessary  to  keep  one- 
137 


SOCIAL   WORK    IN    HOSPITALS 

self  mindful  of  the  fact  that  there  are  other  social 
workers  struggling  against  like  problems.  Ex- 
change of  experience  is  not  only  enlightening  but 
may  be  highly  stimulating. 

Honest  differences  of  opinion  or  of  methods 
among  social  workers  sometimes  lead  to  critical 
judgments  and  misunderstandings  on  both  sides 
which  may  be  destructive  of  valuable  co-operative 
effort.  If,  however,  social  workers  have  faith  in 
one  another's  motives,  differences  of  opinion  and 
method  may  be  wholesome  elements  in  their  rela- 
tions. The  fine  feeling  of  friendly  criticism  that 
has  existed  in  many  cities  between  medical  work- 
ers and  social  workers  has  made  it  possible  for 
them  to  attain  gradually  a  real  understanding  of 
one  another  and  to  exchange  valuable  experience 
and  special  knowledge.  Justifying  one's  point  of 
view  and  testing  one's  theories  in  the  light  of 
friendly  criticism  may  be  made  a  process  of  growth. 

A  helpful  use  of  the  community's  resources  is 
seen  in  the  cases  of  patients  whose  physical  and 
social  need  is  so  involved  as  to  call  for  the  most 
skilful  co-operation  between  medical  and  social 
agencies.  The  following  example  of  the  co- 
operation of  a  social  service  department,  a  dis- 
pensary physician,  a  consul,  an  immigrant  aid 
society,  a  committee  for  homeless  men,  and  the 
patient  himself,  illustrates  better  than  any  dec- 
laration of  principle  the  value  and  effectiveness  of 
a  cordial  and  satisfactory  working  together. 
.38 


WORKING   TOGETHER 

Tony  Milano,  a  bright  faced  Italian  boy  of  twenty, 
wandered  into  a  dispensary  one  day  in  June.  He  com- 
plained that  he  was  losing  his  eyesight  and  that  he 
was  out  of  work  because  of  that.  This  was  the  first 
time  he  had  consulted  an  oculist.  The  doctor  found 
on  examination  a  detached  retina  in  the  right  eye  and 
a  probable  beginning  detachment  in  the  left.  The  prog- 
nosis was  unfavorable.  Tony  needed  daily  observa- 
tion in  the  clinic.  As  he  had  no  relatives  in  this  country 
to  whom  he  might  go  while  he  was  having  treatment, 
a  position  was  created  for  him  at  the  dispensary  where 
he  watched  the  doctors'  automobiles.  This  kept  him 
in  the  open  air  and  made  it  possible  for  him  to  see  the 
doctor  every  day.  He  received  careful  treatment,  to 
which  his  eyes  responded  very  well,  the  vision  in  the 
left  eye  becoming  almost  normal.  The  ultimate  prog- 
nosis, however,  was  unfavorable,  and  it  was  deemed  best 
to  send  Tony  back  to  Italy.  There  his  family  had  a 
market  garden  where  he  could  work  out  of  doors. 

Tony  readily  agreed  to  this  plan  although  he  did  not 
know  how  he  could  get  back.  Also  he  was  troubled 
because  he  had  not  responded  to  a  call  for  military 
duty  and  feared  that  he  might  on  his  return  be  arrested 
and  forced  into  service.  As  Tony  was  not  fit  to  serve 
his  country,  even  if  his  spirit  had  been  willing,  the  con- 
sul was  consulted.  He  gave  Tony  a  large  legal  docu- 
ment asking  for  examination  by  military  authorities 
in  Italy,  with  a  recommendation  for  clemency  and  hos- 
pital care  if  necessary.  He  also  cabled  the  circum- 
stances to  Naples  so  that  there  could  be  no  misunder- 
standing. Free  transportation  was  furnished  through 
the  interest  of  the  Italian  Immigrant  Aid  Society. 
The  agent  of  a  Homeless  Men's  Committee  was  inter- 

'39 


SOCIAL   WORK    IN    HOSPITALS 

ested  in  Tony  and  secured  for  him  proper  clothes  and 
the  necessary  money  for  the  trip.  A  detailed  medical 
account  of  the  case  was  written  to  be  presented  to  the 
physician  in  Italy,  also  a  letter  to  the  father,  outlining 
the  care  that  Tony  should  have  to  protect  and  preserve 
his  eyesight.  These  letters  were  rendered  into  Italian 
by  the  Immigrant  Society.  When  the  day  came  for 
sailing,  the  social  worker  put  Tony  on  board  and  inter- 
ested the  ship's  physician  in  him.  Six  weeks  later  a 
letter  came  from  Tony  saying  that  while  he  missed 
his  American  friends  and  "the  customs  of  our  country," 
he  was  happy  and  contented  and  under  a  physician's 
care. 

Conferences  about  difficult  individual  cases  are 
helpful  in  meeting  some  perplexing  problems. 
The  expert  social  worker  is  always  ready  to  give 
her  experience  and  advice  even  if  the  problem  is 
not  transferred  to  her  for  solution.  Such  con- 
sultation between  specialists  is  not  unlike  the  co- 
operative methods  prevalent  in  medical  practice. 
The  oculist,  aurist,  neurologist,  orthopedist,  pedia- 
trist,  obstetrician,  and  general  practitioner,  each 
working  in  his  own  special  field,  is  still  apprecia- 
tive of  the  other's  special  knowledge  and  holds  it 
essential  to  the  honor  of  the  profession  to  secure 
fora  patient  the  advantage  of  the  specialist's  skill 
whether  or  not  the  patient  himself  has  the  ability 
to  see  the  need.  The  general  practitioner  is  able 
to  determine  when  a  specialist  is  indicated,  but 
further  consultation  is  often  required  to  determine 
whether  the  general  practitioner  should  thereafter 
140 


WORKING   TOGETHER 

conduct  the  treatment  under  advice  or  whether  he 
should  pass  over  the  case  wholly  to  the  specialist. 

The  hospital  social  worker  should  realize  that 
she  herself  is  somewhat  of  a  specialist  and  that  the 
scope  of  social  work  includes  many  other  special- 
ists. The  associated  charities  or  charity  organi- 
zation societies  might  be  considered  the  general 
practitioners;  their  function  is  based  on  a  wide 
general  knowledge  and  on  experience  in  dealing 
with  family  problems.  So  the  children's  socie- 
ties are  the  pediatrists  of  social  work.  Each 
specialist  is  developing  a  kind  of  knowledge  which 
should  be  at  the  service  of  the  hospital  social 
worker,  who  in  turn  should  realize  that  she  too 
has  special  knowledge  to  give. 

Specialism,  unrelated  and  self-centered,  has  its 
dangers.  Specialism  that  appreciates  its  own  field 
of  work,  sees  its  limitations,  and  calls  others  to 
supplement  them,  is  like  one  of  our  bodily  func- 
tions whose  perfect  coordination  with  the  others 
produces  a  happy  state  of  health. 


141 


CHAPTER  IX 
RECORDS 

THE  importance  of  careful  and  thoughtful 
case  records  in  medical-social  service  should 
need  no  argument.  To  record  the  abnormal 
conditions  of  the  individual  in  distress,  the  efforts 
put  forth  to  eliminate  these  conditions,  and  the 
individual's  response  to  those  efforts,  is  as  essential 
in  social  work  as  in  medicine.  Wherever  we  find  a 
steady  refinement  of  medical  case  records,  with 
an  increasingly  accurate  tabulation  of  essential 
facts  concerning  the  patient's  family  history,  past 
history,  habits  and  present  complaints,  the  physi- 
cal examination,  the  progress  of  his  symptoms,  and 
the  treatment,  it  is  one  of  the  most  telling  indica- 
tions of  an  improvement  in  the  quality  of  medical 
practice.  Good  medical  practice  depends  on  this 
careful  and  intelligent  registering  of  the  progress 
of  cases,  both  as  an  aid  to  thorough  examination 
and  treatment  in  the  individual  instance  and — 
through  the  collective  study  and  analysis  of  such 
records — as  a  means  of  improving  the  care  of  future 
patients.  The  use  of  case  records  for  teaching 
medical  students  is  becoming  an  important  means 
of  instruction. 

142 


RECORDS 

Two  sorts  of  records  are  of  interest  for  the  pres- 
ent discussion, — the  social  and  the  medical.  While 
social  records  have  received  a  good  deal  of  consid- 
eration from  thoughtful  social  workers,  they  are 
less  systematic  in  form  and  arrangement  than 
medical  records  in  hospitals.  This  is  due  partly 
to  the  fact  that  the  professional  technique  of 
medicine  is  older,  but  also  to  the  difference  in 
the  kind  of  material  to  be  recorded.  Facts  noted 
in  medical  records  are  concerned  largely  with  con- 
ditions that  can  be  tested  by  instruments  of  pre- 
cision, such  as  the  thermometer,  the  stethoscope, 
and  the  microscope.  With  the  development  of 
scientific  medicine,  physicians  have  gradually 
discriminated  between  physical  facts  that  are 
important  and  those  that  are  unimportant  in 
particular  diseases.  On  the  other  hand,  social 
conditions  are  to  a  larger  degree  dependent  on 
personal  interpretation,  and  thus  accuracy  is  not 
so  easily  obtained. 

Leaders  in  social  work  dealing  with  individuals 
in  distress  have  recognized  the  importance  of 
thoroughness  and  accuracy  and  have  gradually 
evolved  a  technique  of  social  examination  and 
treatment.  During  the  course  of  establishing 
this  technique  they  have  determined  to  some  ex- 
tent what  facts  are  important  to  a  good  social 
record.  The  hospital  social  worker  in  looking  for 
a  suitable  type  of  record  for  her  work  has  therefore 
two  types  to  study  and  to  coordinate:  (i)  existing 
medical  records  (unsocialized) ;  and  (2)  existing 
143 


SOCIAL   WORK    IN    HOSPITALS 

social  records  so  far  relatively  uninfluenced  by  the 
medical  factors  in  the  cases  recorded.  Neither 
type  supplies  her  with  just  the  form  she  needs,  but 
each  is  suggestive  and  each  supplements  the  other. 
Some  hospital  social  workers  who  find  it  difficult 
or  impossible  to  limit  the  number  of  their  cases  to 
those  they  can  deal  with  efficiently,  deliberately 
allow  their  records  to  remain  for  a  time  unwritten 
because  any  attempt  to  keep  them  written  up  to 
date  means  the  neglect  of  patients.  But  we  cannot 
patch  along  in  this  way  indefinitely;  the  work 
must  be  systematized.  Another  type  of  worker 
neglects  records  because  the  individual  patient's 
distress  is  very  appealing,  while  the  record  seems 
dry,  dull,  and  academic.  This  is  a  superficial 
point  of  view  and  should  never  be  tolerated  by 
those  responsible  for  standards  in  hospital  social 
work.  In  every  hospital,  no  matter  how  over- 
worked her  department  may  be,  the  social  worker 
should  keep  before  her  the  ideal  for  which  she 
strives  by  writing  out  in  a  few  cases,  at  least,  a 
satisfactory  account  of  her  plans  and  doings. 
This  accomplishment  will  spur  her  on,  because  it 
is  a  tangible  reminder  of  the  standard  of  work 
which  she  hopes  ultimately  to  attain  in  all  cases. 
By  making  a  thorough  analysis  and  giving  con- 
tinued consideration  to  a  few  recorded  cases,  we 
soon  find  that  these  are  more  intelligently  and  sat- 
isfactorily treated  than  are  the  unrecorded  cases. 
Also,  records  furnish  the  most  valuable  arguments 
wherewith  to  convince  trustees  of  the  need  for 
144 


RECORDS 

more  time  for  case  work  or  the  need  of  an  increase 
of  workers. 

The  confidential  nature  of  records  of  social  work 
should  be  recognized  as  essential.  The  records 
are  necessarily  intimate  and  personal.  Unless 
there  is  a  rigorous  insistence  on  the  protection  of 
our  records,  we  are  betraying  people's  confidence. 
No  worker  has  the  right  to  secure  the  confidence  of 
the  patient,  get  the  details  of  his  story,  and  then 
set  it  down  for  the  indiscriminate  perusal  of  the 
curious.  All  records  of  social  cases  should  be 
filed  in  cabinets  that  are  kept  locked  except  when 
a  reliable  person  is  in  attendance.  Access  to  the 
more  intimate  records  should  be  given  only  to 
persons  whose  interest  in  the  patient  is  justified — 
either  for  the  sake  of  the  individual  patient  or  of 
someone  else  who  may  be  in  similar  need. 

In  the  course  of  an  investigation  by  a  state  com- 
mission into  the  wages  of  women,  a  social  service 
department  was  asked  to  allow  the  records  to  be 
used  for  study  of  the  wages  among  women  in  in- 
dustry who  came  to  the  hospital.  In  this  way 
parts  of  records  that  are  not  too  intimate  may  be 
examined  for  an  impersonal  study  which  is  justi- 
fied by  its  contribution  to  society's  welfare. 

Several  types  of  records  are  in  use  in  existing 
social  service  departments.  The  kind  most  com- 
monly adopted  is  a  general  narrative  following  a 
uniform  initial  record  sheet  on  which  are  tabu- 
lated the  items  most  essential  for  identification 
and  reference.  In  a  few  departments,  notably 

10  145 


SOCIAL   WORK    IN    HOSPITALS 

those  at  the  Boston  Dispensary,  the  Boston  Chil- 
dren's Hospital,  and  the  Union  Hospital  of  Fall 
River,  the  family  unit  is  the  basis  of  the  record; 
that  is,  the  initial  record  sheet  gives  the  family 
group  and  the  patient  merely  as  part  of  that 
group.*  Additional  individual  records  are  made 
for  each  additional  member  of  the  family  who  be- 
comes a  patient. f  In  most  of  the  other  social 
service  departments,  for  example,  Bellevue  Hos- 
pital and  the  University  of  Pennsylvania  Hospital, 
the  individual  is  the  basis  of  the  record. t  The 
first  plan  is  that  generally  used  by  social  agencies 
dealing  with  families  in  distress;  the  second  is  that 
used  by  physicians  writing  records  in  medical 
institutions.  There  are  varying  opinions  as  to 
which  form  of  record  is  the  more  practical  and 
fitting  for  this  new  field  of  work. 

Statistical  and  narrative  records  may  be  used 
for  any  or  all  of  the  following  purposes,  some  of 
which  have  been  previously  mentioned: 

(1)  To  aid  the  memory  of  the  worker. 

(2)  To  portray  the    conduct   of    the  case   so 
satisfactorily    that    a    succeeding    social    worker 
shall  have  a  complete  history  of  all  that  has  al- 
ready been  done. 

(3)  To  aid  the  study  of  methods  of  investiga- 
tion or  treatment  and  to  contribute  to  their  better- 
ment. 

(4)  To  provide  material  for  case-teaching  as  a 

*  See  Appendix,  p.  225.  f  See  Appendix,  p.  226. 

J  See  Appendix,  pp.  227-230. 

146 


RECORDS 

means  of  instructing  students  in  hospital  social 
service. 

(5)  To  promote  medical-social  research. 

(6)  To  deepen  and  clarify  the  worker's  reflec- 
tions upon  the  problems  that  hospital  social  ser- 
vice encounters. 

When  records  are  used  chiefly  as  an  aid  to  the 
memory,  some  workers  have  found  it  best  to  jot 
down  brief  notes  while  at  work,  and  later,  at  in- 
tervals of  two  or  three  weeks,  to  write  or  dictate 
from  these  notes  a  summary  of  what  has  happened. 
Such  a  record  is  helpful  to  the  worker  in  charge  of 
the  case,  but  does  not  portray  the  successive  de- 
tailed steps  by  which  the  work  was  done,  and  may 
be  limited  in  its  usefulness  to  a  successor  obliged 
to  take  up  the  work  suddenly.  Also,  it  fails  to 
show  clearly  what  methods  of  work  are  used. 

The  record  which  is  most  useful  to  those  who 
study  methods  of  work  narrates  in  detail  the  steps 
taken  in  the  progress  of  the  case  and  gives,  as  well, 
occasional  summaries  of  accomplishment.  The 
occasional  summary  also  has  been  found  an  aid  in 
ready  reference  to  different  parts  of  the  record,  and 
a  measure  of  what  has  been  done.  Such  a  sum- 
mary should  contain  a  brief  statement  of  the  most 
important  steps  taken,  the  results  to  date,  and 
the  problems  still  unsolved.  All  correspondence 
received  and  copies  of  important  letters  written 
concerning  any  case  are  often  valuable  for  refer- 
ence and  should  be  filed  with  other  data  in  the 
case  folder.  By  careful  attention  to  details  of 
'47 


SOCIAL   WORK    IN    HOSPITALS 

procedure,  lessons  may  be  learned  from  either  false 
or  wise  steps,  and  a  knowledge  of  good  technique 
thus  secured. 

The  length  of  a  record  is  not  a  test  of  its  value. 
Neither  does  a  copious  but  indiscriminate  accumu- 
lation of  facts  constitute  a  good  record;  they  may, 
indeed,  only  add  confusion  to  an  already  compli- 
cated story.  The  essential  details  should  be  given 
as  briefly  yet  as  graphically  as  possible.  A  skilled 
medical-social  worker  will  distinguish  between  the 
essential  and  non-essential  facts  in  her  records  as 
well  as  in  her  work.  In  all  six  types  of  records 
careful  distinction  should  be  drawn  between  facts 
and  impressions.  The  source  of  information  should 
always  be  given.  As  the  record  proceeds,  contra- 
dictory information  may  be  recorded.  The  pa- 
tient's point  of  view  is  often  warped  by  ill-health 
and  it  is  always  important  to  distinguish  between 
the  facts  and  his  own  interpretation  of  a  situation. 
There  are  sometimes  intentional  misrepresenta- 
tions, the  untruth  of  which  appears  only  on  further 
inquiry.  The  mother  of  a  feeble-minded  child 
gave  to  the  doctor  at  the  hospital  a  history  of 
severe  beatings  and  cruelty  from  her  drunken 
husband  previous  to  the  child's  birth.  She  also 
said  that  her  husband  was  dead.  These  state- 
ments were  recorded  on  the  medical  as  well 
as  the  social  record  of  this  child.  Further  investi- 
gation, through  the  mother's  family,  through  a 
physician  who  had  known  her  for  years,  and 
through  relatives  of  the  father,  proved  that  the 
148 


RECORDS 

woman  was  below  par  mentally  and  morally;  that 
the  father  had  never  been  a  drunkard,  and  that 
he  was  still  living,  although  he  had  long  since 
ceased  to  live  with  his  wife  because  of  her 
immorality. 

Although  all  patients  who  are  under  the  care  of 
the  social  worker  have  physical  needs,  the  facts  nec- 
essary to  understanding  their  problems  are  varied. 
The  problem  of  the  feeble-minded  child  or  insane 
patient  demands  knowledge  of  facts  not  identical 
with  those  required  for  a  wise  handling  of  the 
problems  of  the  tuberculous  patient  or  the  un- 
married girl  facing  motherhood.  Thus,  uniformity 
in  methods  of  investigation,  and  in  consequence 
uniformity  in  social  records,  is  impossible  in  the 
group  of  hospital  social  service  patients  just  as  in 
the  cases  of  distress  appealing  to  a  social  agency. 

The  initial  record  sheet  adopted  by  a  social  ser- 
vice department  is  usually  uniform  for  all  cases. 
The  narrative  record  following  the  initial  sheet  is 
varied  according  to  the  type  of  problem  presented. 
The  use  of  headings  in  the  body  of  the  narrative 
record  serves  as  a  guide  in  orderly  report  of  signifi- 
cant facts  and  helps  to  give  uniformity  and  con- 
sistency to  the  record. 

The  narrative  record  of  a  tuberculous  patient 
should  contain  such  facts  as  these:  personal  habits 
as  to  diet,  sleep,  exercise,  care  of  mouth;  knowledge 
of  precautions  against  infecting  others;  health  of 
relatives ;  history  of  previous  attacks  of  pneumonia, 
bronchitis,  pleurisy,  or  tuberculosis;  home  condi- 
'49 


SOCIAL   WORK    IN    HOSPITALS 

tions  in  detail,  with  special  reference  to  dusty, 
dark,  or  airless  rooms  and  other  unwholesome  sur- 
roundings as  well  as  to  the  opportunities  for  proper 
home  treatment;  employment, — place,  process, 
kind  of  materials  handled,  hours  and  wages;  pos- 
sible resources  for  carrying  out  the  plan  of  treat- 


ment 


The  record  of  a  child,  on  the  other  hand,  should 
lay  chief  emphasis  on  the  home  conditions,  school 
history,  relation  between  parents  and  child,  and 
possibility  of  securing  co-operation  with  family. 

Again,  a  record  of  a  patient  whose  nervous  con- 
dition is  his  chief  source  of  difficulty  calls  for 
special  information  about  the  patient's  heredity; 
his  temperamental  traits  as  interpreted  by  the 
patient  and  those  about  him;  his  relations  with 
his  family  and  those  who  make  up  his  social  circle. 
His  own  attitude  towards  himself,  his  work,  and 
life  in  general,  may  also  disclose  facts  of  con- 
siderable value  to  the  physician.  All  these  phases 
of  the  patient's  personality  are  factors  studied  by 
the  neurologist  in  his  private  practice,  but  the 
limitations  of  time  in  hospital  and  clinic  make 
it  a  practical  impossibility  for  the  neurologist  to 
get  at  all  these  essential  facts.  Hence,  by  helping 
to  get  them,  the  social  worker  who  is  properly 
trained  can  be  of  great  value. 

Some  types  of  cases  which  are  to  be  especially 
studied  or  analyzed,  such  as  occupational  diseases, 
feeble-mindedness,  or  other  diseases  with  social 

*  See  Appendix,  p.  231. 
150 


RECORDS 

bearings,  can  be  more  readily  and  systematically 
recorded  on  definite,  detailed  forms  or  schedules. 
These  schedules  can  be  exactly  adapted  to  the 
object  of  the  inquiry,  and  their  uniformity  then 
makes  a  subsequent  study  much  simpler  and  more 
consistent.  One  such  schedule  has  been  used  in 
the  social  service  department  of  the  Massachusetts 
General  Hospital  for  a  medical-social  study  of  all 
children  who  came  to  the  medical  clinic  suffering 
with  rachitis.  The  object  of  this  study  was,  first, 
to  aid  the  physician  in  discovering  the  social  causes 
and  complications  of  this  disease;  and  second,  on 
the  basis  of  this  knowledge  to  help  make  an  ef- 
fective plan  of  treatment. 

A  similar  plan  is  being  carried  out  with  a  study 
of  gonorrhoeal  vaginitis  in  children  at  the  Boston 
Dispensary  and  Massachusetts  General  Hospital. 
The  complex  of  social  and  moral  as  well  as  physical 
factors  in  this  disease  makes  it  especially  fitting 
that  the  study  should  include  a  search  into  all 
these  aspects  of  it.  Only  on  the  basis  of  careful 
study  from  all  three  points  of  view  can  effective 
treatment  or  prevention  be  hoped  for.  All  the 
patients  were  treated  and  studied  simultaneously 
by  the  doctor  and  the  medical-social  worker.  The 
patients  could  have  no  feeling  that  they  were 
being  investigated  as  types  and  ignored  as  indi- 
viduals. Neither  did  the  social  worker  suffer 
from  the  sense  of  helplessness  common  to  stu- 
dents of  social  abuses  who  study  the  wrongs  and 
must  leave  the  wronged  to  their  fate.  Something 
151 


SOCIAL   WORK    IN    HOSPITALS 

was  done  towards  righting  the  wrongs  discovered 
in  every  case. 

Much  of  the  investigation  of  occupational  dis- 
eases has  been  directed  toward  the  supposed  con- 
nection between  the  occupation  and  the  disease 
without  regard  to  the  personal  habits  and  home 
conditions  of  the  victims.  If  the  way  to  be  scien- 
tific is  to  be  unprejudiced,  we  must  in  any  search 
for  truth  consider  all  the  known  contributing 
causes.  A  hospital  social  service  department 
might  make  important  contributions  to  the  elu- 
cidation of  some  of  these  social  puzzles  by  bring- 
ing together  expert  knowledge  of  the  bodily  dis- 
ease, the  home,  the  habits,  and  the  working  con- 
ditions. In  1910  and  191 1,  the  Social  Service  De- 
partment of  the  Massachusetts  General  Hospital 
carried  on,  with  Dr.  Roger  I.  Lee,  a  study  of  80 
working  girls  who  came  to  the  out-patient  depart- 
ment suffering  from  diseases  that  indicated  a  pro- 
longed debility.*  Each  girl  was  given  a  thorough 
physical  examination  and  a  social  worker  made  a 
study  of  her  habits,  her  home,  and  her  work  con- 
ditions. These  accumulated  facts  in  their  inter- 
relation were  the  basis  of  the  study. 

Dr.  Lee's  conclusion,  that  lack  of  opportunity 
for  industrial  training,  for  education  in  hygiene 
and  thrift,  was  chiefly  responsible  for  keeping 
these  girls  in  poor  health,  was  reached  with  a  due 
sense  of  how  difficult  it  is  to  brand  any  single  fac- 

*  See  Massachusetts  General  Hospital,  Social  Service  Department. 
Sixth  Annual  Report,  1911. 

152 


RECORDS 

tor  as  the  cause.  In  co-operative  research  of  this 
sort,  only  small  beginnings  have  been  made  as 
yet;  the  future  must  show  what  benefit  is  to  be 
found  in  this  phase  of  hospital  social  work. 

The  use  of  records  for  statistical  inquiry  has 
been  repeatedly  exemplified  in  medical  studies  and 
social  investigations.  As  the  experience  of  hospi- 
tal social  workers  increases,  and  as  the  volume  of 
recorded  cases  is  amplified,  the  records  of  these 
cases  are  sure  to  be  examined  much  more  than 
hitherto  by  statistical  methods.  Obviously  such 
examinations  depend  directly,  for  any  fruitful 
results,  on  the  detail  and  accuracy  of  the  original 
statements.  No  reliable  conclusions  can  be  drawn 
from  a  statistical  study  of  unreliable  data.  Thus 
the  hospital  social  worker  should  feel  it  her  duty 
to  put  conscientious  effort  into  the  accounts  which 
she  writes  of  her  cases. 

Another  value  of  accumulated  statistics,  par- 
ticularly in  the  early  stages  of  a  social  service  de- 
partment, lies  in  the  demonstration  which  they 
offer  of  the  work  which  the  department  is  conduct- 
ing. Pioneer  workers  have  secured  local  tele- 
phones, stenographers,  and  additional  workers  be- 
cause they  have  kept  account  of  the  number  of 
times  they  have  had  to  walk  to  the  telephone  on 
another  floor,  the  time  it  has  taken  to  write  records 
and  letters,  and  the  pressure  of  new  patients. 
Kind-hearted  directors  will  often  notice  the  tired 
face  of  the  social  worker  and  possibly  urge  a  vaca- 
tion, when  the  real  need  is  a  limitation  of  work  or 


SOCIAL   WORK    IN    HOSPITALS 

increase  of  workers.  However,  the  best  argument 
for  more  help  is  a  statistical  statement  of  the  bulk 
of  the  work.  The  supervising  group,  if  they  care 
for  real  efficiency  in  the  department  and  have  any 
conception  of  what  social  service  demands  of  the 
worker,  will  be  influenced  by  a  graphic,  statistical 
statement. 

Most  departments  keep  account  of  the  new  pa- 
tients for  the  year,  the  number  of  old  patients,  the 
visits  made,  the  nationality,  age,  sex,  and  illness 
of  each  patient,  as  well  as  of  the  sources  from  which 
they  are  referred.  Some  of  the  departments  keep 
careful  records  of  the  extent  of  their  co-operation 
with  other  agencies.  Such  statistics  kept  from 
year  to  year  indicate  not  only  the  increasing  extent 
to  which  these  other  social  agencies  serve  the  hos- 
pital patients,  but  they  offer  opportunity  to  con- 
sider the  resourcefulness  of  the  hospital  social 
worker  in  doing  the  bulk  of  work  that  comes 
to  her.  Statistics  that  tell  the  true  volume  of  the 
work;  statistics  that  indicate  any  especially  large 
problem,  such  as  tuberculosis  or  children's  dis- 
eases; statistics  that  show  the  use  of  other  agencies 
by  the  workers, — all  these  help  to  tell  the  story  of 
what  the  department  is  doing  and  what  its  policies 
are. 

It  is  well  to  keep  on  file  statistics  that  have  been 
compiled  from  time  to  time,  for  the  further  reason 
that  an  analysis  of  the  department's  activities  at 
a  given  time  is  made  doubly  valuable  by  compari- 
son with  previous  figures.  An  accumulation  of 
'54 


RECORDS 

careful  records  and  accurate  interpretation  of 
recorded  statistics  may  be  made  the  legitimate 
basis  for  a  plea  for  some  special  object.  A  social 
worker  at  the  Washington  University  Hospital 
at  St.  Louis  showed,  through  her  accumulated 
statistics,  that  the  crippled  children  who  had  come 
to  the  hospital  for  braces  and  supervision  were 
not  having  any  opportunities  for  education.  She 
found  that  out  of  the  children  under  the  care  of  the 
hospital  for  one  year,  102  were  of  school  age  but 
not  attending  school.  Practically  all  of  these  chil- 
dren were  in  condition  for  instruction,  but  the  long 
hours,  the  ordinary  seats  and  desks  in  the  public 
school,  were  not  suited  to  them.  The  community 
that  neglects  the  education  of  the  crippled  chil- 
dren is  laying  up  for  itself  many  future  problems. 
This  was  the  argument  of  the  hospital  social 
worker  who  urged  for  the  cripples  not  only  public 
schools  for  regular  elementary  teaching  but  also 
industrial  training  that  would  help  the  physically 
handicapped  to  self-support. 

So  far  it  has  not  been  deemed  convenient  to  file 
together  the  detailed  medical  and  social  records 
in  any  case.  The  medical  records  are  filed  in  one 
room,  the  social  records  in  another.  Yet  it  has 
been  found  important  that  the  doctor  who  is 
studying  the  medical  record  or  treating  the  physi- 
cal needs  of  a  patient  happening  to  be  one  of  the 
few  studied  socially,  should  know  that  the  social 
worker  has  also  done  some  work  on  his  case.  The 
155 


SOCIAL   WORK    IN    HOSPITALS 

additional  data  thus  made  available  justify  a 
remark  or  note  on  the  medical  record.  Most 
social  service  departments  have  devised  some  such 
means  of  identification  as  stamping  in  red  ink, 
"Social  Service  Dept.,"  on  the  medical  record. 

As  the  physicians  realize  more  clearly  the  bear- 
ings of  social  factors  on  the  diagnosis  and  treat- 
ment of  disease,  the  number  of  social  facts  entered 
by  them  on  the  medical  record  increases.  It 
seems  to  me  that  social  facts  secured  by  the 
medical-social  worker  and  of  importance  to  diag- 
nosis and  treatment  should  have  a  place  on  the 
medical  record, — I  mean  such  facts  as  a  family 
history  of  mental  disease,  unwholesome  occupa- 
tion, peculiar  traits  of  character,  and  habits.  It 
must  be  granted,  however,  that  detailed  state- 
ments of  procedure  in  the  social  conduct  of  the 
case  would,  if  added  to  the  medical  record,  merely 
make  it  impractical  for  ready  use.  The  physician, 
who  is  and  always  must  be  chiefly  concerned  with 
the  medical  technique  of  the  case,  does  not  always 
find  the  details  of  social  technique  especially  inter- 
esting. Neither  are  details  of  medical  conditions 
and  treatment  required  on  the  social  records  when 
the  medical  record  is  available.  Means  of  identi- 
fication, by  cross  references  between  social  and 
medical  records,  will,  of  course,  be  always  valuable. 

The  selection  of  such  social  facts  as  are  pertinent 
to  all  medical  records  is  now  receiving  the  atten- 
tion of  some  hospital  physicians  and  hospital  social 
workers.  At  the  Lakeside  Hospital  in  Cleveland 
156 


RECORDS 

each  patient  admitted  to  the  dispensary  has  his 
medical  record  filed  in  a  folder  on  the  outside  of 
which  are  recorded  the  following  facts:  name,  ad- 
dress, year  of  birth,  civil  state,  sex,  nationality, 
occupation,  kind  of  material  handled,  and  em- 
ployer's name.  This  information  is  gathered  for 
the  benefit  of  the  admitting  officer  and  physician, 
not  for  the  social  service  department.  It  is  in- 
teresting to  note  that  the  item  concerning  occupa- 
tion, with  a  statement  as  to  the  employer's  name 
and  the  kind  of  material  handled,  is  filled  out  by 
the  physician  examining  the  patient.  Thus,  the 
possible  relation  of  the  patient's  disease  and  his 
occupation  is  brought  to  the  doctor's  mind.  Many 
other  hospitals  have,  as  a  matter  of  routine,  re- 
corded the  patient's  occupation  in  the  medical 
record,  but  failure  to  appreciate  the  distinction 
between  occupation  and  industry  has  rendered  the 
item  of  little  value.  For  instance,  the  occupation 
may  be  given  as  "laborer"  and  may  mean  any  of 
fifty  different  kinds  of  work  under  that  name.  It 
may  be  given  as  "shoe  factory"  and  mean  any- 
thing from  laster  to  packer.  The  dangers  in 
these  two  kinds  of  work  in  the  shoe  factory  vary 
greatly. 

At  the  Boston  Dispensary  the  medical  records 
of  several  clinics  contain  social  facts  which  the 
visiting  physician  has  found,  through  his  work 
with  the  social  service  department,  important  to 
his  understanding  of  the  patient's  physical  con- 


•57 


SOCIAL   WORK    IN    HOSPITALS 

dition.*  Dr.  W.  Oilman  Thompson  of  New  York 
has  devised  an  analytical  record  form  for  the 
clinical  study  of  diseases  caused  by  industrial 
poisons.  This  is  being  used  at  the  dispensary  of 
the  Cornell  University  Medical  School. 

The  development  of  medical  records  containing 
social  data  marks  an  initial  recognition  by  the 
hospital  of  the  importance  of  a  knowledge  of  social 
facts  to  proper  medical  treatment.  An  interest- 
ing method  of  supplementing  the  medical  record 
by  social  facts  is  to  be  seen  at  the  Children's 
Hospital  of  the  Boston  Dispensary.  The  social 
worker,  who  sees  each  ward  patient,  secures  a  sum- 
mary of  the  social  facts,  which  is  given  to  the 
doctor  and  incorporated  in  the  beginning  of  the 
medical  record. f  At  the  end  of  the  record  appears 
a  statement  of  the  outcome,  medical  and  social. 

The  hospital  social  worker,  through  her  case 
work  and  her  accumulated  knowledge  of  social 
conditions,  has  constant  opportunity  to  bring 
important  social  facts  to  the  attention  of  the  physi- 
cian. She  does  well  to  feel  her  responsibility  and 
recognize  her  opportunity.  To  make  her  contri- 
bution valuable,  she  must  know  her  subject,  for 
medicine  is  a  properly  conservative  profession 
which  accepts  new  types  of  knowledge  only  as 
they  prove  themselves  of  real  benefit  in  the  treat- 
ment of  disease. 

*  See  Appendix,  p.  232.          f  See  Appendix,  p.  233. 
158 


CHAPTER  X 
ORGANIZATION 

HOSPITAL  social  service,  in  the  minds  of  its 
initiators,  is  not  an  independent  enterprise, 
but  an  essential  part  of  hospital  activity- 
Those  who  first  entered  upon  this  branch  of  ser- 
vice believed  that  until  the  influence  of  social 
conditions  on  physical  conditions  is  fully  recog- 
nized and  acted  upon  by  the  hospital  management, 
medical  efficiency  is  impossible  there.  But  this 
truth  had  to  be  demonstrated  before  it  could  be 
accepted  by  hospital  authorities  and  before  hos- 
pital trustees  could  feel  justified  in  expending  their 
funds  for  the  support  of  social  work.  This  is 
natural  enough,  for  many  other  initial  experi- 
ments, such  as  those  with  kindergartens,  play- 
grounds, school  visitors,  and  school  nurses,  were 
made  through  the  interest  of  persons  willing  to 
provide  private  funds.  For  like  reason,  when  the 
initial  social  service  department  was  established 
in  1905  at  the  Massachusetts  General  Hospital,  it 
was  carried  on  by  private  funds. 

The  principles  on  which  the  department  at  the 
Massachusetts  General  Hospital  is  based  have  been 
accepted  by  many  as  fundamental  to  thorough 
'59 


SOCIAL   WORK    IN    HOSPITALS 

hospital  work.  But  the  most  suitable  form  of  or- 
ganization for  carrying  out  these  principles  has 
yet  to  be  determined.  The  relation  of  social  service 
to  the  hospital  administration  and  to  the  doctors; 
the  methods  of  deciding  what  patients  shall  come 
to  the  department;  and  the  best  way  of  using  the 
other  social  agencies  in  the  city,  are  all  details 
which  are  still  in  process  of  being  worked  out. 

There  are  several  forms  of  organization  in  use 
in  social  service  departments  today.  This  diver- 
sity has  both  advantages  and  disadvantages. 
The  lack  of  uniform  standards  of  work  is  a  dis- 
advantage, but,  on  the  other  hand,  the  opportu- 
nity to  try  out  the  effectiveness  of  different  forms  of 
organization  is  an  advantage  in  these  early  stages 
of  growth.  Some  forms  have  proved  good,  some 
poor,  but  none  wholly  destructive  of  the  value  of 
the  service.  It  is  as  yet  impossible  to  class  any 
one  as  the  ideal.  There  is,  however,  one  conclu- 
sion that  has  been  reached  by  all,  independent  of 
the  diversity  of  their  methods;  namely,  that  a 
social  service  department  to  be  most  effective  must 
exist  as  an  integral  part  of  the  hospital,  not  as  an 
affiliated  organisation.  For  the  present  this  is 
impossible  in  some  places,  but  it  is  the  form  of 
organization  that  is  most  likely  to  prevail  in  the 
end. 

Of  the  organizations  already  existing  no  two  are 
exactly  alike.  They  may,  however,  be  grouped 
under  four  general  headings: 

i.  Those  organized  and  controlled  by  the  hos- 
160 


ORGANIZATION 

pital  board;   like  the  Social  Service  Department 
of  the  Boston  Dispensary. 

2.  Those  organized  by  hospital  authority  and 
affiliated  with  the  training  school  for  nurses;  such 
as  the  Social  Service  Bureau  at  Bellevue  Hospital, 
New  York. 

3.  Those  initiated  by  an  individual  or  small 
group  of  individuals  and  supervised  by  a  self- 
appointed  committee  recognized  by  the  hospital; 
such   as   the   department   at   the   Massachusetts 
General  Hospital,  Boston. 

4.  Those  initiated  and  supervised  by  an  outside 
agency,  such  as  the  Associated  Charities  or  a  visit- 
ing nursing  association;    for  example,  the  Social 
Service  Department  of  the  Buffalo  General  Hos- 
pital. 

In  any  one  of  these  four  types  of  organization 
two  principles  are  axiomatic:  first,  the  most  com- 
petent individuals  to  be  found  should  be  put  in 
charge;  second,  a  high  standard  of  work  should  be 
required  of  the  department  by  those  who  control 
and  supervise  it. 

SUPERVISION 

The  question  of  supervision  is  an  important  one. 
If  hospital  social  service  were  merely  an  extension 
of  medical  work,  supervision  by  medical  officers  or 
nurses  alone  would  be  sufficient.  But  since  hos- 
pital social  service  introduces  a  new  element,  not 
found  in  the  technique  of  medicine,  of  nursing,  or 
of  hospital  management,  medical  supervision  of 
ii  161 


SOCIAL   WORK    IN    HOSPITALS 

social  service  should  be  supplemented  by  persons 
experienced  in  social  work  or  at  least  appre- 
ciative of  it.  When  the  supervision  is  entirely 
in  the  hands  of  the  medical  profession,  it  may 
be  successful  in  case  the  worker  is  well  trained 
socially  and  the  doctors,  lacking  special  training 
in  social  work,  are  still  sympathetic  and  ready 
to  feel  the  value  of  a  different  point  of  view. 

A  very  satisfactory  form  of  organization,  from 
the  point  of  view  of  supervision,  is  that  under  the 
direction  of  an  advisory  committee,  official  or 
closely  affiliated  with  the  hospital  organization, 
and  representing  the  varying  interests  within  the 
hospital  and  without.  The  Massachusetts  Gen- 
eral Hospital  Social  Service  Department  has  such 
a  committee,  although  the  department  is  not  as 
yet  an  official  part  of  the  hospital  organization. 
It  numbers  among  its  members  the  superintendent 
of  the  hospital,  one  of  the  board  of  lady  visitors, 
six  members  of  the  medical  staff, — two  medical 
men,  one  surgeon,  one  pediatrist,  one  orthopedist, 
one  neurologist, — two  trained  social  workers,  and 
two  business  men.  The  diversity  of  experience 
contributed  by  such  a  committee  is  valuable  and 
its  discussion  of  matters  important  to  the  depart- 
ment is  well  balanced. 

Social  service  committees,  as  they  are  frequently 
called,  are  often  composed  of  women  who  have 
been  interested  in  the  hospital,  through  a  ladies' 
aid  committee  or  a  board  of  lady  visitors.  They 
have  been  troubled  by  the  sight  of  diverse  social 
162 


ORGANIZATION 

needs  among  the  hospital  patients;  hence  they 
usually  welcome  the  advent  of  hospital  social  ser- 
vice as  an  important  aid.  The  St.  Louis  Chil- 
dren's Hospital  has  such  a  social  service  committee. 
In  some  instances  the  women  on  the  committee 
have  paid  the  salary  of  a  worker  and  served  as 
volunteers  under  her.  But  though  these  com- 
mittees have  supervision  of  the  work  in  certain  de- 
tails, the  ultimate  control  of  policies  usually  rests 
with  the  hospital  board.  Such  a  group  acting  in 
a  supervisory  capacity  contributes  personal  ser- 
vice and  enthusiasm,  but  it  may  lack  the  advan- 
tages of  the  more  diversified  group  in  which  the 
hospital  physicians  and  trained  social  workers 
balance  the  point  of  view  of  the  laity  and  bring 
expert  knowledge  of  the  complicated  problems 
that  come  up  for  settlement. 

Wherever  hospital  social  service  needs  to  be 
interpreted  and  explained  to  sceptical  hospital 
authorities,  and  wherever  it  is  dependent  for  finan- 
cial support  upon  private  sources,  I  believe  that  an 
advisory  committee  is  of  great  help,  even  though 
the  final  control  is  still  in  the  hands  of  the  hospital. 
When  standards  of  work  have  been  evolved  and 
generally  accepted  and  when  there  are  in  the  field 
thoroughly  trained  workers  who  can  be  given  free- 
dom to  develop  the  department  according  to  the 
accepted  standards  of  social  work,  less  responsi- 
bility for  details  will  rest  on  the  supervisory  com- 
mittee. 

At  the  present  time  there  are  many  elementary 
163 


SOCIAL   WORK    IN    HOSPITALS 

social  problems  which  from  time  to  time  arise  and 
float  about  the  hospitals  unsolved.  Not  only 
questions  of  adjustment  within  the  hospital  and 
without,  but  also  the  fundamental  question  of 
what  the  hospital  social  worker  shall  do,  remain 
unanswered  in  many  hospitals.  The  type  of  case 
to  transfer  to  another  agency,  the  length  to  which 
a  patient  should  be  followed  in  order  to  fulfil  the 
ideal  of  effective  medical  treatment,  the  kind  of 
problem  to  recognize  as  insoluble  by  a  given  force 
of  workers  or  with  unsuitable  facilities;  the  whole 
problem  of  how  best  to  conserve  the  department's 
forces  and  put  the  best  effort  where  it  will  do  the 
most  good, — all  these  matters  must  be  threshed 
out  before  a  satisfactory  plan  of  social  work  can 
be  constructed  in  medical  institutions.  Such 
questions  should  be  considered  by  those  who  best 
understand  both  the  ideals  of  the  medical-social 
worker  and  the  needs  of  the  hospital. 

SELECTION    OF    CASES 

Various  plans  have  been  evolved  for  selecting 
from  the  whole  clinic  the  patients  who  most  need 
social  service.  The  workers  who  deal  with  ward 
patients  usually  find  that  the  desk  where  the  ad- 
mitting physician  does  his  work  is  a  strategic 
point  for  noting  urgent  social  needs;  as,  for  in- 
stance, in  the  case  of  a  patient  in  need  of  immediate 
care  in  the  hospital,  obviously  troubled  because 
his  family  do  not  know  that  he  is  sick  and  because 
he  does  not  know  what  will  become  of  them  during 
•64 


ORGANIZATION 

his  illness.  Visits  to  the  wards  also  reveal,  through 
friendly  talks  with  patients,  burdens  that  the 
social  worker  can  lighten.  Through  careful  study 
of  patients  about  to  be  discharged,  the  danger  of 
a  thwarted  convalescence  is  now  and  then  dis- 
covered. Many  ward  social  workers  question  each 
patient  about  to  be  discharged  and  if  home  con- 
ditions are  unsuitable  for  convalescence,  arrange- 
ments are  made  for  entrance  to  a  convalescent 
home.  The  superintendent,  resident  physician, 
visiting  physicians,  and  nurses  often  refer  patients 
who  seem  to  them  to  need  the  help  of  the  social 
worker,  but  they  do  not  always  pick  out  those  most 
in  need  of  such  help.  - 

In  dispensaries  or  out-patient  departments, 
patients  requiring  social  care  may  be  selected  in 
several  ways.  The  admission  desk  is  again  a  valu- 
able point  at  which  to  learn  about  social  complica- 
tions. In  several  dispensaries, — the  Massachu- 
setts Charitable  Eye  and  Ear  Infirmary,  Boston 
Dispensary,  Cambridge  Hospital,  and  Memorial 
hospital  at  Worcester,  for  example, — the  social 
worker  is  placed  at  the  admission  desk.  Her  first 
duty,  like  that  of  the  lady  almoner  in  the  London 
hospitals,  is  to  pass  on  the  question  of  admission 
of  patients  to  free  treatment  by  an  inquiry  into 
their  financial  status.  In  most  instances  she  is 
also  on  the  lookout  for  patients  needing  social 
service.  It  is  of  great  importance  to  have  at  the 
admission  desk  someone  possessing  social  knowl- 
edge and  social  sympathy. 
165 


SOCIAL   WORK    IN    HOSPITALS 

The  admitting  physician  who  knows  little  of 
the  widely  varying  standards  of  living  among  the 
patients,  of  the  range  of  wages  for  various  occu- 
pations, of  the  seasonal  trades  with  their  irregular 
incomes,  and  of  the  cost  of  living,  has  not  a  sound 
basis  on  which  to  determine  whether  or  not  pa- 
tients applying  for  treatment  are  suitable  for 
admission  to  a  free  clinic.  Correctly  to  determine 
the  fact  of  suitability  for  admission  is  as  important 
as  to  discriminate  regarding  the  clinic  in  which  the 
patient  belongs.  It  is  no  more  possible  to  make  a 
social  diagnosis  by  seeing  the  clothes  people  wear 
than  to  make  a  medical  diagnosis  with  one's  eyes 
shut. 

I  once  knew  a  patient  who  borrowed  the  best 
clothes  of  the  whole  family  when  she  came  to  the 
hospital,  out  of  a  more  or  less  conscious  respect  for 
the  institution.  She  "looked  as  though  she  could 
pay,"  although  in  reality  she  was  barely  able  to  get 
along  because  of  her  irregularity  in  work  and  in- 
come and  her  precarious  health. 

In  the  third  annual  report  of  the  Massachusetts 
Charitable  Eye  and  Ear  Infirmary  of  Boston  some 
of  the  opportunities  of  the  social  worker  at  the  ad- 
mission desk  are  brought  out : 

"The  Registration  Department  of  a  hospital, 
usually  considered  a  cut  and  dried,  most  imper- 
sonal piece  of  work,  is  in  reality  the  most  interest- 
ing of  the  hospital  departments.  When  you  have 
asked  a  patient  his  name,  his  age,  his  birthplace, 
166 


ORGANIZATION 

his  present  address,  his  occupation  and  wages, 
you  know  a  great  deal  about  him.  .  .  . 

"Mrs.  Antonio  Luigi  comes  to  the  registration 
desk  with  little  Tony,  eyes  much  inflamed. 

'"What  is  the  little  boy's  name?'  is  answered 
fully,  'Tony  Luigi,  same  his  fada's  name.' 

"'How  old  is  he?' 

'"Nexta  mont'  tree  year.' 

'"Where  was  he  born, — in  Italy?' 

"'Geno',  ten  mont'  an'  he  come  here.' 

'"What  is  his  father's  work?' 

'"Pick  and  shovel,  but  he  no  work  now.  He 
seecka  da  bed  now  tree  week,  seeck,  alia  time.' 

'"Hasn't  he  had  a  doctor  or  gone  to  a  hospital?' 

"'No  doct',  no  hospitale.' 

"'What  seems  to  be  the  trouble?' 

'"Oh,  he  cough,  cough  alia  time/ 

"And  when  you  have  registered  Tony,  you  know 
that  he  is  one  of  five  children ;  that  his  parents  have 
been  in  America  two  years;  that  his  father  is  a 
laborer,  who  has  had  irregular  work;  that  the 
family  has  lived  in  three  rooms  in  a  crowded  neigh- 
borhood on  an  average  of  $5.00  a  week;  and  that 
the  father  is  not  improbably  tuberculous." 

Another  social  worker  who  has  had  experience 
at  the  admission  desk  says: 

"The  interest  shown  at  the  registration  desk 
brings  the  patients  back  to  it  with  a  statement  of 
their  special  difficulty  or  problem. 

"  Margaret  Carney,  a  widow,  fifty  years  of  age, 
167 


SOCIAL   WORK    IN    HOSPITALS 

lives  in  a  nearby  city.  At  the  registration  desk  it 
is  learned  that  she  has  been  a  mill  worker  but  be- 
cause of  failing  eyesight  she  has  been  unemployed 
for  some  months.  The  support  of  the  family  is  a 
child,  also  a  mill  worker,  who  earns  $5.50  a  week. 
Later  she  returns  to  the  registration  desk  to  say 
that  she  is  unable  to  pay  for  the  medicines  which 
have  been  prescribed  by  the  doctor  and  she  will 
be  unable  to  return  in  two  days,  as  he  has  asked 
her  to  do,  because  of  the  expense.  Free  medicine 
is  secured  for  her  and  she  is  referred  to  a  charitable 
society  in  her  home  city  for  the  necessary  help  to 
enable  her  to  return.  This  society  wrote  in  reply 
that  such  help  would  be  given  her  and  that  she  is 
'an  old  friend.'  During  a  period  of  nine  months 
she  returned  when  it  was  necessary  and  her  vision 
improved  greatly,  so  that  she  was  able  to  work 
when  work  was  to  be  found." 

It  is  at  the  admission  desk  that  the  social  worker 
can  get  the  pulse  of  the  hospital,  as  the  flood  of 
humanity  passes  through  her  hands  seeking  the 
services  of  the  institution.  It  may  be  her  duty 
to  know  whence  this  flood  comes  and  whither  it 
goes.  She  may  be  commissioned  to  find  out  why 
and  how  the  community  uses  such  service  as  the 
hospital  gives.  Such  a  medical-social  worker  is 
placed  at  the  admission  desk  of  the  Boston  Dis- 
pensary. Her  duty  is  not  only  to  pass  on  the  ad- 
mission of  patients  to  a  free  clinic  but  to  be  the 
student  who  analyses  the  dispensary  population 
168 


ORGANIZATION 

in  its  social  bearings.  If,  while  admitting  a  pa- 
tient, she  learns  facts  that  are  of  importance  to 
the  physician,  she  passes  them  on  to  the  clinic. 
Her  chief  function,  however,  is  in  the  field  of  medi- 
cal-social investigation.  It  is  for  her  to  study  the 
economic  groups  which  the  hospital  serves,  the 
question  of  "hospital  and  dispensary  abuse,"  the 
alternative  for  patients  refused  admission  to  a  free 
clinic,  and  the  relation  of  the  dispensary  to  other 
medical  and  charitable  institutions.  She  may  also 
guide  medical-social  researches,  as,  for  example, 
in  occupational  diseases  and  industrial  accidents. 
In  the  majority  of  dispensaries  the  selection  of 
patients  referred  to  the  social  service  department 
is  left  entirely  to  the  physicians  in  the  clinics. 
Slips  similar  to  those  used  for  prescriptions  are 
placed  in  the  different  rooms.*  When  the  physi- 
cian finds  a  patient  who  seems  to  require  social 
treatment,  he  indicates  on  the  blank  the  physical 
treatment,  suggests  the  social  need,  and  refers  him 
to  the  social  service  department.  Such  selections 
as  these  are  more  or  less  indiscriminate.  The 
busy  physician  has  neither  the  time  nor  the  special 
knowledge  to  select  those  most  in  need  of  social 
assistance.  On  the  other  hand,  if  the  social  worker 
at  the  admission  desk  selects  patients  wholly  by 
reason  of  what  she  learns  on  the  social  side,  she 
is  not  necessarily  selecting  those  most  in  need  of 
medical-social  work;  her  point  of  view  towards 
the  patient  is  too  far  removed  from  the  considera- 

*  See  Appendix,  pp.  234,  235. 
169 


SOCIAL   WORK    IN    HOSPITALS 

tion  of  his  physical  condition.  What  we  need  is  a 
joint  medical-social  diagnosis  of  a  patient's  con- 
dition by  the  doctor  and  the  social  worker. 

The  practical  working  of  such  a  plan  can  be  seen 
at  the  small  Children's  Hospital  connected  with 
the  Boston  Dispensary.  A  social  worker  considers 
the  social  needs  of  all  patients  on  admission.  She 
visits  the  home  of  every  child  to  see  if  the  parents 
understand  the  child's  trouble  and  to  learn  if  con- 
ditions are  fit  for  the  child's  return.  She  makes 
ward  visits  with  the  visiting  physician  and  tells 
him  of  the  home  conditions  she  has  found  and  of 
any  plan  she  may  have  for  the  patient.  She  in 
turn  learns  of  the  progress  of  the  patient's  physical 
condition  and  the  doctor's  wishes  for  after  care. 
No  patient  is  discharged  until  the  social  worker, 
as  well  as  the  physician,  has  signed  the  discharge 
slip.  Only  those  who  have  seen  carefully  con- 
sidered plans  upset  by  the  thoughtless  discharge  of 
a  patient  without  any  notification  to  the  social 
worker  can  truly  appreciate  the  value  of  such  close 
collaboration  of  the  two  factors  operative  in  suc- 
cessful hospital  treatment.  A  similar  plan  is  being 
carried  out  at  the  Children's  Hospital  in  Buffalo. 

Although  such  co-operation  is  being  tried  in 
several  other  places,  the  Boston  Dispensary  has 
elaborated  most  thoroughly  and  consistently  the 
method  of  using  the  social  worker  in  the  clinics, 
where  she  is  as  closely  in  touch  with  the  doctors  as 
are  the  clinic  nurses.  Here  the  social  worker  sees 
the  patient  first,  and  secures  from  him  important 
170 


ORGANIZATION 

social  facts  which  she  passes  on  to  the  doctor.* 
With  this  twofold  evidence  before  them,  and  know- 
ing the  number  of  patients  that  must  be  dealt 
with,  they  decide  together  what  patients  can  be 
properly  cared  for  by  advice  and  supervision  in 
the  clinic,  and  what  patients  should  be  more  in- 
tensively cared  for  outside  the  clinic  by  the  social 
worker. 

In  a  suggestive  paper  on  the  Social  Aspects  of 
a  Medical  Institution,  read  at  the  National  Con- 
ference of  Charities  and  Correction  in  1912, 
Michael  M.  Davis,  Jr.,  Director  of  the  Boston 
Dispensary,  pointed  out  that  the  next  step  in  the 
development  of  hospital  social  service  will  prob- 
ably be  an  adequate  plan  for  selecting  the  patients 
who  need  social  treatment  in  order  to  make  medi- 
cal treatment  effective.  He  suggested  that  the 
social  necessities  of  all  who  resort  to  a  medical 
institution  have  never  been  measured  and  that 
any  general  estimate  based  on  a  comparatively 
small  group  of  patients  referred  to  the  social  ser- 
vice department  is  not  sound.  Basing  his  classi- 
fication on  a  medical-social  studyf  of  the  new 
patients  coming  to  the  Boston  Dispensary  on 
three  different  days,  he  has  classified  tentatively 
under  four  headings,  the  problems,  social  as  well 
as  medical,  which  present  themselves: 

"TYPE  ONE.  Patients  whose  social  problems  are 
evident  and  acute.  These  problems  must  be  solved 

*  See  Appendix,  pp.  232,  236-237.        t  See  Appendix,  pp.  236-237. 
171 


SOCIAL   WORK    IN    HOSPITALS 

promptly  if  the  patient  is  to  be  in  a  position  to  receive 
any  effective  treatment. 

Examples:  A  baby  of  fifteen  months,  ill-nourished, 
enlarged  tonsils,  pharyngitis.  Mother  a  dish-washer 
in  a  restaurant,  deserted  by  husband. 

Married  woman  of  forty,  chronic  arthritis  of  pha- 
langes of  right  hand,  scoliosis,  teeth  almost  gone,  severe 
headaches.  Takes  bromo-seltzer  in  large  quantities. 
Cannot  understand  English.  Three  children  at  school, 
husband  a  tailor. 

Young  unmarried  woman,  illegitimate  child.  Both 
syphilitic. 

"TYPE  Two.  Patients  whose  social  problem  is 
not  acute,  but  whose  disease  is  one  dangerous  to 
others.  It  is  a  serious  matter  if  a  patient  suffering 
from  such  a  disease  goes  about  without  continued 
care  and  ultimate  cure.  The  interests  of  the  com- 
munity in  such  a  case  are  paramount  to  the  needs  or 
wishes  of  the  individual  patient. 

Examples:  Woman  of  twenty-one,  recently  married. 
Syphilis.  Syphilitic  throat  lesions. 

Married  man  of  thirty-two,  second  stage  tubercu- 
losis; two  children  of  school  age  and  baby  under  two. 

"TYPE  THREE.  In  this  type  there  exists  no 
acute  problem  of  poverty,  ignorance,  or  employment; 
but  examination  at  the  first  visit  indicates  a  disease 
which  means  that  the  patient  should  return  several 
times  for  treatment.  Unless  the  work  of  the  physician 
who  makes  the  diagnosis  is  to  be  wasted,  so  far  as  ser- 
vice to  the  patient  and  the  community  is  concerned, 
this  return  should  be  brought  about.  It  is  the  duty  of 
the  institution  to  adapt  its  methods  so  that  patients  are 
most  likely  to  return  and  so  that  the  most  economical 
172 


ORGANIZATION 

and  efficient  means  are  used  for  following  up  patients 
to  such  an  extent  as  is  necessary  without  squandering 
effort  upon  hopeless  or  unresponsive  cases. 

Examples:  Man  of  fifty-two,  married,  no  children. 
Clerk.  Rheumatism. 

Woman  of  fifty-three,  married,  two  children,  one  at 
school  and  one  working;  husband  a  laborer,  work  un- 
steady. Indigestion  and  bad  teeth. 

Boy,  age  four.  Father  is  a  helper  in  a  garage. 
Three  other  children,  one  working.  Adenoids,  hyper- 
trophied  tonsils,  operative;  dermatitis. 

"TYPE  FOUR.  No  acute  social  problem  exists 
and  treatment  of  patient  can  be  completed  at  the 
first  visit,  or,  if  a  few  additional  treatments  be  required, 
the  disorder  is  such  as  to  occasion  discomfort  sufficient 
to  insure  patient's  return. 

Examples:  Toothache,  requiring  extraction;  sup- 
posed need  for  eye-glasses,  found  on  examination  not 
to  exist;  stye  on  the  eyelid. 

"What  is  the  relative  proportion  of  these  types? 

"From  a  study  at  the  Boston  Dispensary  I  can  say 
tentatively: 

"Type  One  and  Type  Two  (acute  problems  calling 
for  medical-social  case  work):  25  to  30  per  cent  of  all 
patients. 

"Type  Three  (problems  requiring  social  work  but 
mainly  by  clinical  methods) :  40  to  50  per  cent. 

"Type  Four  (patients  not  requiring  any  following 
up  or  other  definite  social  work) :  25  per  cent." 

In  explanation  of  this  Mr.  Davis  goes  on  to  say: 

"These  percentages  are,  of  course,  tentative  even 
«73 


SOCIAL   WORK    IN    HOSPITALS 

for  the  single  institution  to  which  they  refer.  But  I 
believe  that  this  kind  of  classification  is  of  fundamental 
importance  to  the  social  work  of  medical  institutions. 
Such  work  falls  into  two  main  types,  which  for  the  sake 
of  better  titles  1  will  call  the  'case  work  type'  and  the 
'clinical  type.'  To  the  latter  very  little  attention  has 
thus  far  been  given.  It  seems  that  it  would  apply  to 
one-half  of  all  the  patients,  while  the  kind  of  work 
with  which  we  are  more  familiar,  the  case  work  type, 
appears  to  apply  to  less  than  one-third.  The  clinical 
type  of  social  work  requires  persons  as  well  trained  as 
those  who  pursue  case  work, — for  most  individuals 
carry  on  both  kinds,  though  with  different  patients, — 
but  the  clinical  work  is  not  necessarily  pursued  accord- 
ing to  those  methods  or  with  that  point  of  view  which 
has  usually  been  regarded  as  effective  in  the  care  and 
rehabilitation  of  needy  families  in  their  homes." 

On  a  careful  study  of  Mr.  Davis'  results  we 
may  hope  to  base  a  new  form  of  hospital  organiza- 
tion which  shall  serve  fully  the  patient's  needs, 
both  physical  and  social. 

SUBDIVISION  OF  SOCIAL  WORK  IN  HOSPITALS 

Specialization  of  function  has  developed  in  most 
of  the  existing  social  service  departments  as  soon 
as  the  number  of  workers  has  grown  beyond  the 
original  one  or  two.  Under  the  supervision  of  the 
head  of  the  department,  there  may  be  workers  in 
charge  of  tuberculous  patients,  sex  problems,  sick 
children,  psychoneurotics,  patients  with  venereal 
disease,  cripples  and  the  physically  handicapped. 
When  classification  of  patients  to  be  treated  by 
«74 


ORGANIZATION 

social  workers  is  made  according  to  the  physical 
disability,  social  treatment  starts  from  the  proper 
point. 

These  divisions  of  work  do  not  necessarily  cor- 
respond to  the  chief  social  needs  of  the  institution. 
The  call  for  a  special  worker  for  psychoneurotics 
may  result  from  the  interest  of  some  physician 
who  desires  to  refer  to  the  department  many 
patients  who  should  have  more  than  he  can  give 
them.  A  special  worker  for  children,  for  unmar- 
ried mothers,  or  for  the  handicapped,  may  be 
placed  in  the  department  by  some  donor  particu- 
larly interested  in  that  type  of  unfortunates. 

A  wave  of  hopefulness — for  example,  about 
tuberculosis — leads  to  the  appointment  of  some 
workers.  Others  serve  a  physician's  particular 
interest;  for  example,  in  chorea.  Others  create 
their  own  position  by  the  strength  of  a  domin- 
ating personality.  Yet  all  the  while,  hundreds  of 
wretched  patients  may  go  quite  unaided,  not  be- 
cause we  do  not  recognize  their  need  of  help,  but 
because  we  are  powerless  to  supply  it.  The  pitiful 
group  of  alcoholic  patients  exemplifies  this  point. 

In  the  more  or  less  accidental  and  irregular 
forms  above  indicated  social  service  has  sprung  up 
in  more  than  a  hundred  hospitals  since  1905.  The 
social  worker  has  usually  made  her  greatest  effort 
in  whatever  direction  she  found  the  superintend- 
ent, the  doctors,  or  the  nurses  most  sympathetic. 
This  effort  has  often  been  neither  satisfactory  nor 


SOCIAL   WORK    IN    HOSPITALS 

systematic,  and  no  one  has  felt  this  more  than  the 
workers  themselves. 

MEDICO-SOCIAL  SURVEYS 

We  shall  probably  soon  come  to  feel  that  fully 
as  important  as  the  establishment  of  social  service 
in  any  hospital  is  a  study  of  the  social  needs  of 
the  institution  before  social  service  is  established. 
We  should  study  the  demand  before  we  furnish  a 
supply.  Only  recently,  however,  has  such  in- 
vestigation been  appreciated.  The  value  of  a 
preliminary  survey,  often  applied  in  other  fields  of 
social  work  but  rarely  in  hospitals,  is  an  offshoot 
of  the  simple  principle  that  one  should  know  as 
much  as  possible  of  a  problem  before  tackling  it. 

Partial  surveys  have  already  been  made  at  the 
Boston  Dispensary  and  at  the  Massachusetts 
General  Hospital.  These  surveys  have  involved 
a  critical  review  of  the  medical  work  of  the  clinics, 
over  a  significant  period  of  time.*  For  instance, 
at  the  Eye  Clinic  of  the  Boston  Dispensary,  a 
study  was  made  of  the  records  of  all  the  new  pa- 
tients who  came  to  the  clinic  for  three  months  in 
1910  (263  patients)  and  again  for  three  months  in 
1912  (301  patients).  Social  service  was  started  in 
the  clinic  in  1911.  In  1910,  66>£  per  cent  of  all 
glasses  prescribed  by  the  oculist  were  not  called 
for.  During  a  corresponding  three  months  in 
1912  only  8  per  cent  of  the  glasses  prescribed  were 
not  called  for.  There  was  also  an  increase  in  the 
number  of  visits  made  at  the  clinic  by  the  patients 

*See  Appendix,  p.  238. 
I76 


ORGANIZATION 

with  iritis  and  keratitis.  The  number  of  visits 
per  patient  increased  50  per  cent  after  social  ser- 
vice was  established.  The  number  of  patients 
cured  increased  from  9  per  cent  to  31  per  cent; 
the  number  improved  increased  from  44  per  cent 
to  55  per  cent,  while  the  number  of  patients  lost 
sight  of  decreased  from  37  per  cent  to  14  per  cent 

The  object  of  a  survey  of  the  Mental  Clinic 
records  was  stated  as  a  means  "to  secure  an  im- 
personal self-criticism,  gaining  not  only  indica- 
tions of  the  strength  and  weakness  in  the  work  but 
suggestions  for  the  improvement  of  methods  and 
attainment  of  results  with  a  minimum  of  effort 
and  expense."  A  second  study  was  made  after 
the  medical-social  worker  had  joined  the  clinic. 
Some  of  the  significant  facts  brought  out  by  these 
studies  showed  the  value  of  social  service  to  the 
clinic.  During  1911,  59  per  cent  of  the  patients 
were  lost  sight  of,  while  during  the  six  months  of 
1912  covered  by  this  study  only  5  per  cent  were 
lost.  During  the  first  period,  80  per  cent  of  the 
patients  had  "deferred  diagnoses,"  that  is,  no 
diagnoses  at  all,  while  during  the  second  period 
only  9  per  cent  had  deferred  diagnoses.  It  was 
also  brought  out  that  40  per  cent  of  the  mental 
cases  treated  in  the  clinic  during  the  second  period 
were  transferred  to  other  institutions  for  care,  as 
compared  with  16  per  cent  during  the  first  period. 

A  survey  of  the  Children's  Clinic  at  the  Mass- 
achusetts General  Hospital  covered  a  period  of 
six  months  from  October,  1911,  to  April,  1912. 

12  I77 


SOCIAL   WORK    IN    HOSPITALS 

The  study  was  made  to  ascertain  a  basis  for  or- 
ganization of  social  work  in  that  clinic.*  The 
schedule  sheet  was  formulated  by  the  visiting 
physician  with  the  co-operation  of  the  social  ser- 
vice department.  One  of  the  interesting  results 
of  this  self-criticism  was  the  revelation  of  the  fact 
that  the  largest  group  of  children  coming  to  the 
clinic  were  under  one  year  of  age  while  the  im- 
pression had  existed  that  this  was  a  "clinic  of 
school  children."  Another  fact  brought  out  was 
that  out  of  779  patients,  426  came  to  the  clinic 
only  once.  A  further  analysis  of  these  426  pa- 
tients showed  that  they  represented  59  per  cent 
of  the  total  patients  suffering  from  improper  feed- 
ing, 52  per  cent  of  those  with  chorea,  56  per 
cent  of  those  with  bronchitis,  26  per  cent  of 
those  suffering  from  heart  disease,  and  12  per  cent 
of  those  with  tuberculosis. 

These  surveys,  although  limited,  have  brought 
out  clearly  some  of  the  haphazard  methods  now 
used  in  the  treatment  of  dispensary  patients  and 
have  indicated  especially  two  needs :  better  records, 
and  more  systematic  methods  of  following  up  the 
patient  who  fails  to  return.  The  results  achieved 
in  these  clinics,  while  unsatisfactory,  are  probably 
as  good  as  those  to  be  found  elsewhere. 

These  surveys  have  also  given  us  a  rough  test 
of  efficiency  in  dispensary  service  and  have  brought 
out  some  defects  that  can  be  and  a  re  being  rectified. 
Every  step  in  the  growth  of  hospital  social  service 

*  See  Appendix,  p.  239. 
I78 


ORGANIZATION 

emphasizes  the  necessity  of  making  the  department 
an  integral  part  of  the  institution,  identified  with 
all  the  community  relations  of  the  hospital. 
Social  workers  should  help  to  keep  fresh  in  the 
minds  of  all  who  work  within  the  hospital  walls 
the  consciousness  that  it  is  not  the  separate  but 
the  combined  results  of  the  hospital  activities 
which  are  far-reaching  and  essential  to  the  well- 
being  of  the  community. 


179 


CHAPTER  XI 
WORKERS 

THE  choice  of  workers  is  the  most  important 
consideration  in  the  development  of  a  social 
service  department.  The  qualifications  de- 
sirable in  a  worker  are  those  needed  to  bridge  the 
gap  between  the  community  and  its  servant,  the 
hospital.  She  can  make  each  more  conscious  of 
the  other,  and  can  guide  each  to  draw  more  fully 
upon  the  other's  resources.  Social  work  has  been 
carried  on  most  pleasantly  in  some  hospitals  with- 
out stimulating  either  the  work  of  the  physician 
or  that  of  the  social  agencies  in  the  community. 
But  this  is  not  the  kind  of  social  work  we  are  dis- 
cussing. Often  the  only  gain  has  been  a  little 
more  kindness  to  the  patients  confined  in  the 
hospital.  Without  underestimating  the  value  of 
personal  kindliness  in  an  institution  where  it  is  so 
desirable,  I  wish,  nevertheless,  to  point  out  that 
it  is  only  one  aspect,  not  by  any  means  the  whole, 
of  hospital  social  service.  A  physician  connected 
with  a  hospital  that  "had  social  service"  testified 
that  he  knew  of  nothing  that  the  worker  did  ex- 
cept to  visit  the  ward  in  the  capacity  of  a  friend; 
he  had  never  "come  in  contact  with  her  in  his 
1 80 


WORKERS 

work,"  and  could  tell  little  about  her  value;  he 
believed  she  was  much  appreciated  by  the  pa- 
tients. Skilled  social  work,  like  nursing,  includes 
acts  prompted  by  kindly  interest;  but  it  should 
include  far  more.  A  social  worker  who  has  failed 
to  give  some,  at  least,  of  the  physicians  in  the 
hospital  a  sense  of  her  value,  in  helping  to  secure 
effective  treatment,  has  failed  to  perform  the  sort 
of  service  which  is  considered  in  this  book. 

The  social  worker  must  sometimes  be  a  dis- 
turbing element  if  she  is  to  make  her  proper  con- 
tribution to  the  establishment  of  social  work  in  a 
hospital.  Any  innovation  in  a  conservative  insti- 
tution is  likely  to  be  a  bit  disconcerting,  not  in 
the  sense  of  producing  useless  irritation  but  by 
disturbing  some  old  habits.  The  worker  should 
have  this  quality  of  stimulating  without  annoying 
others,  both  within  and  without  the  hospital.  If 
she  is  to  be  the  head  of  a  group  of  workers,  such  a 
gift  will  be  invaluable.  If  she  is  to  be  the  only 
worker,  it  may  enable  her  to  gather  helpers  about 
her  or  to  inspire  in  all  who  come  in  contact  with 
her  the  desire  to  help. 

A  hospital  social  worker  should  have  these 
among  her  more  special  qualifications:  First, 
she  should  have  the  technical  skill  of  the  social 
expert,  and  the  ability  to  adapt  that  skill  to  the 
needs  of  a  medical  institution.  Next,  she  should 
have  tact  and  such  understanding  of  the  physi- 
cian's habit  of  thought  as  will  enable  her  to  ap- 
proach him  on  the  professional  side  so  that  he 
181 


SOCIAL   WORK    IN    HOSPITALS 

will  not  be  jarred  by  the  sense  of  an  "outsider" 
in  his  clinic.  Third,  she  should  have  the  initiative 
and  imagination  that  are  necessary  to  introduce 
the  social  point  of  view  into  the  hospital;  she 
should  also  have  the  power  to  insist  that  the  social 
point  of  view,  as  well  as  the  medical,  receives  its 
due  recognition.  Fourth,  she  should  have  the 
instincts  of  a  teacher,  but  also  the  receptiveness  of 
a  student.  She  should  have  organizing  ability, 
open-mindedness,  and,  last  but  not  least,  a  sense 
of  humor.  This  may  seem  like  a  catalogue  of  im- 
possible virtues;  it  is  difficult  to  find  them  all  in 
one  person,  but  it  is  not  hopeless.  These  abili- 
ties can  be  in  part  acquired  through  training,  but 
to  a  larger  degree  they  are  necessarily  matters  of 
native  endowment.  Possessing  them,  the  worker 
will  not  only  bring  efficiency  to  her  daily  tasks,  but 
she  will  remain  sufficiently  plastic  to  increase  her 
efficiency  through  experience. 

In  the  head  worker  many  qualities  are  desirable, 
but  among  them  three  may  be  selected  which  are 
of  especial  importance:  a  trained  social  point  of 
view,  executive  ability,  and  a  discriminating  open- 
mindedness.  If  there  is  to  be  but  one  worker, 
the  task  of  choosing  her  is  more  difficult  than  if 
she  is  to  be  one  of  a  group.  A  group  of  workers  may 
be  so  selected  as  to  supplement  one  another's  quali- 
ties and  thus  bring  to  the  department  the  variety 
of  qualities  that  is  desirable.  For  instance,  the 
trained  social  worker  without  medical  knowledge 
and  the  trained  nurse  without  social  knowledge 
182 


WORKERS 

have  several  times  done  splendid  team-work, 
each  having  a  due  appreciation  of  the  other's  con- 
tribution to  the  department.  For  the  pioneer 
worker,  steadfastness  of  purpose  and  patience  are 
most  helpful  assets.  No  matter  how  much  she 
may  bring  to  this  new  field,  she  has  to  win  her  way 
step  by  step;  for  in  no  hospital  is  the  way  wholly 
clear  for  the  establishment  and  conduct  of  a  social 
service  department.  While  there  may  be  many 
who  sympathize  with  her  efforts,  there  are  always 
others  who  are  not  interested.  There  may  even 
be  some  who  are  antagonistic,  who  regard  her  ad- 
vent as  an  unwarranted  criticism  of  a  "well-or- 
dered institution"  rather  than  as  a  promise  of 
increased  efficiency.  But  consistent,  thorough 
work  will  finally  have  recognition,  and  the  pioneer 
efforts  that  are  wisely  guided  always  justify  them- 
selves within  a  few  years. 

The  ability  to  co-operate  easily  with  the  physi- 
cian is  necessary  for  various  reasons.  First  of  all 
because,  as  already  noted,  social  work  is  nothing 
more  than  a  superstructure  upon  a  foundation  of 
good  medical  work.  To  build  well  on  this  founda- 
tion the  medical-social  worker  should  have  a  sym- 
pathetic understanding  of  the  well-seasoned  pur- 
poses and  often  disappointed  hopes  of  medical 
treatment;  and  she  should  know  how  to  reinforce 
them.  She  should  also  make  the  physician  in- 
creasingly acquainted  with  her  plans  and  efforts 
for  the  patient.  In  talking  with  physicians  she 
should  be  constantly  mindful  of  their  busy  lives, 
183 


SOCIAL   WORK    IN    HOSPITALS 

and  should  avoid  all  unnecessary  interference  with 
the  routine  which  saves  their  time.  Physicians 
are  most  generous  in  explaining  physical  condi- 
tions to  the  hospital  social  worker  who  has  not 
special  medical  knowledge;  they  are  beginning  to 
recognize,  in  turn,  that  they  must  often  learn  from 
the  social  worker  the  significance  of  social  diag- 
nosis and  treatment.  Doctors,  nurses,  social 
workers,  and  patients  are  alternately  teachers  and 
students,  giving  and  receiving  according  to  their 
lights. 

If  the  hospital  social  worker  is  to  be  the  com- 
munity's interpreter,  if  she  is  to  remind  the  insti- 
tution she  serves  of  its  external  relations,  she  must 
hold  these  points  of  view  distinct  in  her  mind. 
She  must  see  the  hospital  from  the  point  of  view 
of  the  laity,  as  well  as  the  community  from  the 
point  of  view  of  the  hospital.  She  should  live  as 
nearly  as  possible  the  wholesome  life  of  a  citizen, 
and  continually  strive  to  see  the  hospital  as  it 
looks  to  the  stranger  within  its  gates.  On  the 
other  hand,  her  understanding  of  the  huge,  com- 
plex, and  busy  institution  will  often  enable  her  to 
interpret  to  outside  charitable  agencies  some  of  the 
mysteries  and  paradoxes  of  hospital  rules,  which 
they  do  not  readily  appreciate.  The  necessity  for 
"red  tape," — the  admission,  classification,  and  dis- 
charge of  patients;  the  physician's  professional 
point  of  view,  his  secrecies,  points  of  honor,  and 
habits  of  order;  the  custom  of  sending  ward  pa- 
tients away  as  soon  as  their  recovery  is  sufficient  to 
184 


WORKERS 

permit  it, — is  a  feature  of  hospital  management 
which  is  likely  to  be  misunderstood.  A  reason- 
able explanation  of  these  conditions  will  often  help 
to  foster  good  feeling  between  the  hospital  and  the 
people  outside. 

In  order  to  co-operate  wisely  and  effectively 
with  other  social  workers  in  the  city,  the  hospital 
social  worker  must  be  able  to  appreciate  their 
functions  and  to  work  side  by  side  with  them. 
Only  thus  will  they  learn  her  functions.  Also,  it 
is  by  keeping  closely  in  touch  with  the  social 
workers  outside,  by  reading  current  literature  on 
social  problems,  and  by  seeing  clearly  her  work 
in  its  whole  significance  that  the  social  worker 
in  a  hospital  can  continue  to  contribute  her  part 
to  the  solution  of  institutional  problems.  Noth- 
ing is  more  easy  and  more  deadening  than  to 
drop  into  institutionalism.  Habit  and  routine 
are  the  methods  by  which  we  gradually  simplify 
our  oft-repeated  actions,  and  allow  their  per- 
formance to  be  controlled  by  unconscious  mech- 
anism. It  is  of  prime  importance  for  the  med- 
ical-social worker  to  keep  herself  from  getting 
into  habits  that  blind  her  to  any  aspects  of  the 
patient's  life  that  are  fresh  and  acute  to  the  pa- 
tient himself  as  he  comes  to  the  hospital  for  the 
first  time.  His  dislike  of  smells,  bare  walls,  white 
coats  "like  butchers,"  his  fears  that  neighbors  will 
find  out  what  is  written  on  the  hospital  record,  his 
dislike  of  nursing  by  women  not  of  his  own  family, 
are  often  forgotten.  By  reminding  herself  con- 
•85 


SOCIAL   WORK    IN    HOSPITALS 

stantly  that  each  patient  has  many  interests  and 
ties  other  than  those  associated  with  his  disease, 
the  worker  can  best  preserve  fresh  and  vivid  her 
social  point  of  view.  Thus,  while  appreciating 
the  attitude  of  the  physician  and  of  the  hospital 
authorities,  she  must  always  keep  clearly  in  mind 
the  feelings  of  the  patient  whose  representative 
she  is. 

In  organizing  her  work  for  its  greatest  effective- 
ness, she  should  become  acquainted  with  the  town 
or  city  in  which  she  is  placed,  and  its  activities 
both  within  and  without  the  hospital.  She  should 
know  her  special  problems  as  they  are  presented 
through  the  patients  she  serves,  and  the  special 
resources  in  the  community  for  meeting  those 
problems.  It  is  wise  for  her  to  start  her  labors  in 
that  ward  or  that  out-patient  clinic  where  she  can 
most  surely  hope  for  response  and  enthusiastic  co- 
operation. But  from  whatever  point  she  starts  she 
should  aim  finally  to  have  the  social  work  so  per- 
meate the  institution  as  to  lose  any  sharp  delinea- 
tion of  its  field.  While  she  must  always  be  the 
agent  through  whom  a  special  work  is  to  be  ac- 
complished, the  spirit  of  social  service  should  be- 
come that  "integrating  factor"  that  binds  all 
functions  of  the  hospital  together. 

Social  service  alone  can  never  accomplish  this; 
it  must  result  from  the  co-operative  effort  of  all 
concerned.  To  the  social  worker,  however,  the 
opportunity  is  often  presented  of  weaving  together 
many  of  the  strands.  She  sees  the  patient  in  his 
186 


WORKERS 

relation  to  the  admitting  physician,  the  visiting 
physician,  the  nurse,  and  the  visiting  clergyman, 
and  can  help  each  of  them  to  know  what  the  whole 
man  needs. 

Social  service  entails  upon  her  the  use  of  a  plas- 
tic organizing  faculty.  Nothing  defined  and  pre- 
conceived can  be  superimposed  upon  a  hospital  or 
dispensary.  Each  medical  institution  is  different 
from  others  in  its  organization  and  needs.  Social 
service,  as  a  supplementary  element,  should  fit 
into  the  organization  as  easily  as  possible.  The 
worker  must  accept  the  situation  as  she  finds  it, 
and  so  develop  her  function  within  it  that  she  shall 
accomplish  her  end  with  as  great  effectiveness  and 
harmony  as  possible. 

Probably  no  question  with  regard  to  the  choice 
of  workers  has  been  more  discussed  than  that  of  the 
fitness  of  the  trained  nurse  for  medical-social  ser- 
vice. While  the  value  of  some  of  her  special 
knowledge  is  not  called  into  question,  there  has 
been  a  difference  of  opinion  as  to  her  fitness  for  this 
service  by  virtue  of  her  nurse's  training  alone. 
It  is  contended  that  since  hospital  social  service 
deals  with  sick  patients,  the  nurse  is  peculiarly 
fitted  for  this  service.  That  she  may  have  the 
ability  to  work  smoothly  with  the  other  nurses 
and  with  doctors,  that  she  may  have  keen  human 
sympathies,  and  that  she  may  have  a  social  point 
of  view  are  granted;  but  that  she  can  possess  and 
use  the  technique  of  social  work  without  having 

187 


SOCIAL   WORK    IN    HOSPITALS 

had  experience  or  training  in  that  special  field  is 
obviously  not  probable. 

After  the  technical  clinical  training  which  the 
nurse  receives  in  two  or  three  years  of  confining, 
arduous  study  and  labor  within  the  hospital  walls, 
she  will  still  need  a  knowledge  of  the  community 
and  its  resources,  an  appreciation  of  the  various 
standards  of  living  represented  among  the  hospi- 
tal patients,  a  familiarity  with  the  habits  and  pre- 
judices of  various  nationalities,  and  especially  a 
knowledge  of  the  ideals  and  methods  by  which 
constructive  social  work  is  sustained.  This  knowl- 
edge should  be  a  part  of  her  equipment  before  she 
can  do  the  best  social  work  for  the  hospital. 

There  are  fundamental  differences  between 
nursing  and  social  work.  The  relation  of  a  pa- 
tient to  a  nurse  is  one  of  dependence.  If  the  pa- 
tient is  sick  enough  to  need  a  nurse's  care,  he  must 
be  spared  all  responsibility  and  give  himself  up 
to  the  physician  and  nurse  who  seek  to  restore 
him  to  well-being.  Most  nurses  become  restless 
during  the  convalescence  of  a  patient.  Their 
technical  ability,  which  they  naturally  enjoy  using, 
is  no  longer  called  upon.  During  convalescence 
the  needs  of  a  patient  become  changed.  He  must 
begin  to  depend  on  himself;  the  habit  of  depen- 
dence must  be  broken  and  a  constructive  effort 
made  to  help  him  toward  self  help.  The  nurse, 
unless  she  is  one  of  the  comparatively  few  who  have 
had  experience  in  teaching,  has  little  preparation 
for  this  service,  because  patients  rarely  complete 


WORKERS 

their  convalescence  in  the  hospital.  When  she  no 
longer  feels  that  the  need  for  her  personal,  skilful 
aid  is  urgent,  the  inspiration  for  her  work  is  gone. 
It  is  partly  because  of  a  natural  characteristic,  the 
desire  to  be  needed,  that  women  have  been  such 
successful  nurses,  and  that  nursing  will  always  be 
one  of  the  greatest  professions  open  to  them. 

While  social  work  is  by  no  means  a  greater  or  a 
nobler  service,  it  has  quite  distinctive  aims.  Good 
social  work  is  constructive,  for  its  conscious  aim 
is  the  independence  of  the  beneficiary.  It  strives 
to  prevent  the  dependent  applicant  for  charity 
from  submitting  to  contributed  aid;  it  also  strives 
to  make  him  do  what  he  can  for  himself.  Herein 
lies  the  present  distinction  between  nursing  as 
it  is  practiced  in  our  hospitals  and  social  work. 
Again,  from  a  consideration  of  the  patient  as  an 
isolated  individual  whose  personal  abnormality 
must  be  rectified,  the  social  worker  must  learn  to 
consider  the  individual  in  all  his  human  relations. 
As  a  nurse,  she  must  fix  her  attention  on  the 
troubles  of  one  person  alone;  as  a  social  worker, 
she  must  see  the  patient's  illness  as  only  part  of  a 
larger  and  more  intricate  difficulty, — the  key  per- 
haps to  a  house  of  sorrows.  The  outlook  becomes 
divergent  rather  than  convergent,  and  new  and 
different  points  of  observation  are  called  upon. 
This  does  not  mean  that  nurses  cannot  and  have 
not  developed  into  efficient  social  workers.  There 
are  many  such ;  but  our  training  schools  for  nurses 
alone  have  not  produced  them. 
189 


SOCIAL   WORK    IN    HOSPITALS 

The  nurse  has  not  only  to  acquire  new  abilities, 
but  to  overcome  old  tendencies,  the  result  of  her 
special  training,  before  she  can  succeed  in  social 
work.  The  desirability  of  originality  and  initia- 
tive in  social  work  is  apparent.  The  training 
of  the  nurse,  as  it  is  carried  on  in  the  majority  of 
our  training  schools,  does  not  stimulate  these 
powers,  for  a  prolonged  period  of  silent  submission 
to  discipline  is  characteristic  of  her  training-school 
experience.  She  does  not  learn  to  think  inde- 
pendently, to  dare,  to  lead.  As  a  social  worker, 
however,  her  position  is  not  one  of  subservience  to 
orders.  Rather  is  it  one  of  independent  judgment 
and  constructive  planning  in  her  own  sphere. 
Her  decision  with  regard  to  the  social  aspects  of  a 
situation,  and  her  formulation  of  a  plan  of  treat- 
ment, must  be  an  independent  contribution. 
The  final  decision  will  not  rest  wholly  with  her 
nor  with  the  physician,  but  will  grow  naturally 
out  of  the  balancing  of  the  two  points  of  view. 
Neither  takes  orders  from  the  other.  To  the 
nurse  this  involves  a  necessary  shifting  of  her  hab- 
its of  mind.  She  is  no  longer  the  doctor's  medical 
assistant,  but  his  consultant,  called  as  an  expert 
from  another  field  of  service. 

The  trained  social  worker  who  has  no  medical 
knowledge,  is  also  handicapped  in  hospital  social 
work,  although  she  will  find  her  social  knowledge 
and  experience  essential  in  such  work.  She  has 
much  to  learn  concerning  physical  conditions 
before  she  can  work  intelligently.  In  fact,  medi- 
190 


WORKERS 

cal  knowledge  is  an  important  asset  to  the  social 
worker  wherever  she  is.  There  is  at  present  no 
means  of  getting  just  the  kind  of  medical  knowl- 
edge that  is  needed  except  by  daily  contact  with 
those  who  will  pass  on  the  necessary  instruction. 
Time  may  show  that  much  of  the  technical  bed- 
side training  of  the  nurse  is  unused  in  social  work, 
and  that  much  definite  medical  knowledge  con- 
cerning causes  and  progress  of  disease,  treatment 
of  long  convalescence,  sanitation,  significance  of 
predisposing  causes  for  disease  (as  fatigue,  mal- 
nutrition, etc.),  special  knowledge  of  tuberculosis, 
of  contagion,  hygiene,  and  public  health  methods, 
— all  vitally  important  in  social  work, — are  not 
emphasized  in  the  nurse's  training. 

A  special  course  for  medical-social  work  is 
needed,  and  so  a  new  profession  may  be  developed. 
The  nursing  profession  is  an  outgrowth  from  the 
medical  profession.  The  medical  subjects  valu- 
able to  bedside  service  have  been  given  rather 
grudgingly  to  the  nurse  and  have  been  supple- 
mented by  special  methods  devised  to  make  the 
patient  more  comfortable  through  the  nurse's 
personal  care.  In  the  same  way,  the  profession 
of  the  hospital  social  worker,  which  is  neither  medi- 
cine nor  nursing,  will  have  to  receive  from  medi- 
cine those  aspects  of  medical  knowledge  vital  to 
its  new  function,  supplemented  by  special  knowl- 
edge from  sociology.  Workers  so  trained  would 
have  some  comprehension  of  two  professions, 
which  would  make  them  valuable  both  in  medical 
191 


SOCIAL   WORK    IN    HOSPITALS 

and  social  problems,  and  helpful  to  the  patient 
both  in  his  physical  and  in  his  social  difficulties. 
For  the  present,  the  lack  of  properly  trained 
women  has  thrown  upon  the  social  service  depart- 
ments the  responsibility  of  sending  out  workers, 
inadequately  prepared,  and  after  only  a  few  months 
of  preliminary  training,  to  establish  similar  depart- 
ments in  other  hospitals.  The  lack  of  standards 
that  has  become  apparent  as  a  result  of  this  use  of 
untrained  people  sometimes  seems  to  jeopardize 
the  best  interests  of  the  whole  movement.  Never- 
theless, a  large  measure  of  success  has  attended 
the  hospital  social  worker  wherever  she  has  been 
established.  She  has  met  a  need,  although  im- 
perfectly, and  demonstrated  the  importance  of 
the  place  she  is  called  to  fill. 

VOLUNTEERS 

As  I  have  previously  stated,  volunteers  from 
the  laity  and  clergy  had  long  visited  sick  patients, 
and  tried  by  devoted  personal  service  to  meet  their 
material  and  spiritual  needs,  before  professional 
social  service  was  thought  of  as  an  integral  part  of 
the  care  of  hospital  patients.  The  service  of  vol- 
unteers, therefore,  cannot  be  regarded  as  an  innova- 
tion. Neither  should  we  regard  it  as  supplanted, 
but  rather  as  made  more  effective,  through  the  ad- 
vent of  the  professional  social  worker.  Both  in  the 
wards  of  the  hospital  and  in  the  out-patient  clinics, 
the  social  worker,  being  officially  recognized  and 
trained  to  observation,  has  special  opportunities 
192 


WORKERS 

which  enable  her  to  discern  the  needs  of  the  pa- 
tients more  accurately  than  can  be  done  by  the 
untrained  volunteer.  Her  constant  opportunity 
for  discovering  obscure  difficulties  and  distress 
will  give  a  still  wider  field  of  usefulness  to  the  vol- 
unteer than  was  ever  before  possible. 

In  some  hospitals,  volunteer  service  in  the  wards 
has  remained  independent  of  the  social  service 
departments,  the  work  of  the  professionals  being 
largely  confined  to  the  dispensary.  Such  loose 
organization  and  such  division  between  two  groups 
performing  so  nearly  the  same  function  in  the 
same  institution  indicate  a  distinct  weakness.  Not 
only  are  overlapping  and  duplication  possible,  but 
each  group  misses  the  peculiar  contribution  which 
the  other  has  to  make.  An  organization  by  which 
the  paid  social  worker,  in  virtue  of  her  official  posi- 
tion and  special  training,  supervises  and  guides 
the  work  of  the  volunteers  brings  the  best  results 
in  the  end. 

It  would  be  difficult  to  estimate  the  measure  of 
helpfulness  that  has  been  contributed  by  volun- 
teers since  the  organization  of  social  service  de- 
partments. The  enthusiasm  and  devotion  with 
which  they  have  co-operated  with  the  trained 
workers  has  been  a  great  stimulus  and  support 
to  those  who  carried  the  responsibility  of  the 
pioneer  organization.  Not  only  have  they  helped 
materially  in  the  day's  work,  but  they  have  also 
conveyed  to  the  hospital  authorities  and  to  those 
in  the  community  from  whom  support  is  drawn, 
13  193 


SOCIAL   WORK    IN    HOSPITALS 

an  appreciation  of  the  importance  of  the  depart- 
ment. Highly  efficient  professional  social  workers 
have  been  trained  in  the  volunteer  group. 

In  hospital  social  service  the  distinction  be- 
tween paid  and  unpaid  workers  is  not  necessarily 
that  between  trained  and  untrained,  for  many 
volunteers  are  as  competent  and  experienced  as 
paid  workers.  Many  of  the  volunteers  have,  from 
the  beginning,  been  in  close  touch  with  the  details 
of  the  department's  activities.  Especially  is  this 
true  at  the  Bellevue  and  the  University  of  Penn- 
sylvania Hospitals.  They  have  worked  shoulder 
to  shoulder  with  paid  workers.  The  result  has  been 
a  growth  in  their  experience  and  ability  until  in 
some  hospitals  they  may  help,  under  sympathetic 
guidance,  to  stimulate  and  to  contribute  valuable 
aid  in  every  division  of  social  work. 

There  are  several  cautions  to  be  observed,  how- 
ever, in  the  selection  and  direction  of  volunteers. 
In  the  first  place,  care  must  be  taken  to  prevent 
their  number  being  too  large  for  careful  super- 
vision of  the  details  of  their  work.  If  the  number 
increases  beyond  the  ability  of  the  trained  worker 
properly  to  supervise  and  develop  the  efficiency  of 
the  volunteer  corps,  volunteer  service  may  become 
a  weakness  rather  than  a  strength.  In  cities 
where  the  hospital  social  work  has  become  popular 
enough  to  excite  the  interest  of  persons  who  can 
give  volunteer  service,  the  paid  worker  can  select 
from  the  various  applicants  those  whose  service 
will  mean  most  to  the  department. 
194 


WORKERS 

There  may  be  among  the  applicants  some  who 
do  not  seek  personal  relations  with  patients,  but 
who  are  especially  fitted  for  statistical  or  clerical 
work.  In  one  department  a  volunteer  assumed  the 
tabulation  of  all  routine  statistics  that  were  kept 
by  the  department;  another  took  charge  of  the 
catalogue  of  the  locations  from  which  patients 
come.  It  is  only  just  to  the  patients  and  to  the 
volunteers  themselves  to  take  pains  in  their  se- 
lection and  in  fitting  their  tasks  to  their  abilities. 
Making  them  responsible  for  a  piece  of  work  and 
holding  them  to  a  high  standard  in  it  is  by  far  the 
most  satisfactory  arrangement  for  all  concerned. 
There  is  no  satisfaction  to  the  helper  in  work  poorly 
done,  nor  in  uselessly  wandering  along  without 
guidance.  Imagination  on  the  part  of  the  paid 
worker  in  discovering  ways  for  employing  the 
special  gifts  of  her  volunteers  multiplies  her  use- 
fulness. Some  can  be  of  great  service  in  the  de- 
tails of  office  work;  some  are  well  fitted  to  inter- 
view patients;  some  undertake  correspondence 
with  patients,  writing  friendly  letters  to  those  who 
are  leading  a  tedious  existence  in  a  sanatorium; 
and  others  are  well  suited  for  visiting  the  patients 
in  their  homes.  To  study  the  capacity  of  each 
applicant  and  then  to  give  each  an  opportunity, 
under  direction,  to  make  the  fullest  use  of  her 
capacity,  develops  the  most  efficient  corps. 

Certain  conditions  should  be  insisted  upon  with 
all  workers,  volunteer  as  well  as  paid.  Prompt- 
ness and  regularity  are  essential.  A  schedule  of 
195 


SOCIAL   WORK    IN    HOSPITALS 

the  volunteer  workers,  with  the  hours  at  which 
they  are  responsible  to  the  department,  is  indis- 
pensable; and  it  is  equally  indispensable  that  the 
volunteers  should  keep  to  their  schedule.  This  is 
particularly  true  for  the  volunteers  who  give  ser- 
vice in  an  office  where  desk  room  is  limited,  and 
for  whom  work  must  be  planned  out  in  advance. 
Those  who  undertake  such  work  as  making  a 
home  visit,  or  arranging  for  the  transfer  of  a  pa- 
tient to  an  institution  for  convalescents,  need  not 
be  held  so  rigidly  to  stated  hours.  In  the  case  of 
volunteers  acting  outside  the  hospital,  a  written 
report  of  what  has  been  done,  noted  briefly  and 
concisely  and  given  promptly  to  the  paid  worker, 
offers  opportunity  for  both  the  paid  worker  and 
the  volunteer  to  consider  together  what  has  been 
done.  As  the  variety  of  work  and  responsibility 
placed  upon  volunteers  increases,  such  reports 
mark  the  progress  of  the  volunteers'  development. 
The  supervision  of  volunteers  should  be  pains- 
taking, especially  of  volunteers  visiting  patients 
in  their  homes.  They  should  not  be  asked  to  take 
the  full  responsibility  of  such  cases,  even  though 
they  be  the  only  persons  coming  directly  in  contact 
with  the  patients.  That  is  unjust  both  to  the 
patients  and  to  the  volunteers.  The  final  re- 
sponsibility for  all  activities  of  the  department 
must  rest  upon  the  paid  workers.  Some  paid 
worker  should  be  intimately  acquainted  with  all 
the  service  of  the  volunteers,  so  that  what  they  are 
doing  may  be  known  to  the  department  and  can 
196 


WORKERS 

be  closely  connected  with  the  physical  treatment 
planned  by  the  doctor. 

A  helpful  way  of  eliminating  the  repetition  of 
personal  instructions  to  new  volunteers  is  to  have 
a  notebook  of  instructions  which  each  new  volun- 
teer can  peruse  when  she  first  comes  to  the  depart- 
ment and  can  consult  from  time  to  time.  Infor- 
mation, such  as  the  names  of  the  hospital  officials 
and  members  of  the  social  service  department, 
hours  for  admission  of  patients  and  for  visiting  in 
wards,  rules  governing  the  care  of  records,  loca- 
tion of  maps,  street  directories,  writing  supplies, — 
in  fact,  any  kind  of  information  that  should  be 
common  knowledge  among  the  workers  in  the 
department  and  that  will  help  to  make  the  depart- 
ment's work  simpler,  will  be  found  suitable  for 
such  a  book. 

A  weekly  conference  between  volunteers  and 
paid  workers  is  an  admirable  way  to  give  volunteers 
valuable  experience  and  to  give  them  insight  into 
hospital  social  service.  Such  a  conference  gives 
opportunity  not  only  to  discuss  the  difficult  prob- 
lems of  some  of  the  individual  cases,  but  to  indicate 
the  fundamental  principles  underlying  the  analysis 
and  treatment  of  all  the  cases. 

Many  times  the  workers  feel  the  need  of  help 
from  professions  other  than  those  available  in 
the  hospital,  the  help  of  the  lawyer,  the  minister, 
the  psychologist,  and  the  linguist.  Every  com- 
munity has  members  of  these  and  other  profes- 
sions ready  to  give  volunteer  service  to  those  in 
197 


SOCIAL   WORK    IN    HOSPITALS 

trouble.  It  rests  with  the  social  worker  to  find 
them. 

Sometimes  students  of  medicine,  of  divinity, 
of  economics,  and  students  in  schools  for  social 
workers  have  given  useful  volunteer  service  in  the 
social  service  department  of  a  hospital,  while  ob- 
taining valuable  experience  for  themselves.  Dr. 
Emerson's  employment  of  medical  students  for 
social  work  in  order  that  they  might  get  an  appre- 
ciation of  the  social  side  of  their  patients'  lives 
suggests  a  way  of  increasing  the  number  of  helpers. 
A  divinity  student  offered  several  hours  each  week 
to  a  social  service  department,  saying: 

"If  I  am  to  be  of  any  use  in  the  ministry,  I 
must  know  more  intimately  than  I  do  the  kinds 
of  trouble  that  people  have  to  meet.  It  seems 
to  me  that  hospital  social  service  would  give  me 
the  best  opportunity  to  know  how  to  be  of  help 
in  every  kind  of  distress." 

In  New  York,  Chicago,  Boston,  and  St.  Louis 
students  from  the  schools  for  social  workers  are 
assigned  to  hospital  social  service  departments  for 
practical  work.  Such  students  thus  have  oppor- 
tunity to  gain  experience  analogous  to  that  which 
the  medical  student  has  in  the  hospital  clinic. 
The  value  of  the  experience  depends  on  the  fitness 
of  the  student  and  the  kind  of  supervision  given. 
If  the  student  is  truly  interested  in  hospital  social 
service,  and  if  regularity,  conscientiousness,  and 
accurate  reporting  of  all  work  done  are  demanded 
of  her,  she  should  complete  her  relations  with  the 
198 


WORKERS 

department  with  a  clear  conception  of  what  hos- 
pital social  service  is  and  with  an  idea  of  methods 
and  standards  which  ought  to  be  valuable  to  her 
in  any  field  of  social  effort.  Such  experience  is, 
of  course,  limited,  and  is  designed  only  to  give 
the  student  a  glimpse  of  medical-social  service  so 
that  she  may  have  an  appreciation  of  the  hospital 
worker's  function.  This  should  not  be  confused 
with  a  special  training  for  hospital  social  service, 
such  as  that  now  offered  at  the  New  York  School 
of  Philanthropy  and  at  the  Boston  School  for 
Social  Workers.  The  special  course  at  the  Boston 
School  offers  several  months  of  practical  work 
under  supervision  in  the  Social  Service  Depart- 
ment of  the  Boston  Dispensary  or  the  Massachu- 
setts General  Hospital.  Problems  in  case  work, 
record  making,  and  organization  are  discussed  in 
weekly  conferences,  and  a  course  of  lectures  on 
medical  subjects  of  social  significance  is  attended. 
Hospital  social  service,  as  it  develops,  must  take 
form  from  the  personalities  of  those  who  are 
molding  it.  For  this  reason,  the  choice  of  work- 
ers, both  paid  and  volunteer,  must  be  considered 
of  prime  importance.  Workers  who  are  carefully 
selected  for  ability  in  organizing  and  interpreting 
the  work,  and  who  possess  a  balance  of  qualities 
fit  to  meet  the  multitudinous  needs  of  the  service 
with  a  never-failing  spirit  of  sympathetic  interest 
in  the  patients,  will  bring  the  best  promise  of  suc- 
cess. 


199 


CHAPTER  XII 

THE  FUTURE  OF  HOSPITAL  SOCIAL  SER- 
VICE 

THE  hospital  social  service  movement  is  a 
part  of  that  stirring  of  hearts  and  minds 
which  presages  the  awakening  of  our  social 
conscience.    The  movements  for  industrial  wel- 
fare and  for  the  elimination  of  child  labor;   the 
campaign  for  moral  prophylaxis;   the  awakening 
of  the  churches  to  a  larger  usefulness;    and  the 
growing  interest  in  a  eugenics  program  partake  of 
the  same  spirit. 

These  movements  are  fundamentally  based  on 
a  belief  in  our  moral  responsibility  for  one  an- 
other. "Prevention"  and  "efficiency"  are  their 
watchwords,  and  the  spirit  of  social  service  is  their 
impelling  motive.  Hospital  Social  Service  is  then 
the  tangible  evidence  of  the  working  of  the  social 
conscience  in  the  hospital.  While  it  will  always 
express  itself  tangibly  in  the  activities  of  hospital 
social  workers,  its  influence  is  likely  to  spread 
beyond  the  institution  and  make  contributions 
to  medicine,  to  nursing,  and  to  general  social 
work. 

200 


FUTURE  OF  HOSPITAL  SOCIAL  SERVICE 

HOSPITAL  SOCIAL  SERVICE  AND  THE  HOSPITAL. 
A  lasting  contribution  of  hospital  social  service  to 
the  institution  in  which  it  is  conducted  can  be 
made  only  when  that  service  becomes  an  expression 
of  forces  within  the  hospital.  The  initial  stimulus 
may  come  from  without,  but  no  vital  social  work 
for  the  institution  can  result  until  the  principles 
of  hospital  social  service  are  so  implanted  within 
the  institution  that  growth  from  within  is  assured. 
Those  in  control  of  the  hospital  activities — the 
officers,  physicians,  and  nurses — must  have  a  social 
interest  before  their  institution  can  become  socially 
efficient  in  any  measure  approximating  the  ideal. 
For  many  years  past,  the  real  interests  of  most 
medical  institutions  have  been  concentrated  on 
the  perfection  of  their  professional  technique,  on 
the  efficiency  of  construction  of  buildings,  and  on 
the  economics  of  hospital  management.  This 
phase  has  been  that  of  the  institution's  youth. 
Youth  is  necessarily  the  time  dedicated  to  self 
development  and  to  acquiring  the  tools  of  ex- 
perience, and  it  is  inevitably  accompanied  by  a 
self  interest  which  is  as  unconscious  as  it  is  tran- 
sient. When  the  tools,  whose  use  has  been  thus 
laboriously  attained,  begin  to  be  tested  on  the  real 
issues  of  life,  and  their  efficiency  questioned,  the 
period  of  youth  passes.  The  idea  of  hospital 
social  service  expresses  this  very  maturity  of  hos- 
pital experience,  for  it  asks  whether  this  "per- 
fected hospital  technique"  does  after  all  give  ef- 
fective treatment  to  patients.  Such  a  question 


SOCIAL   WORK    IN    HOSPITALS 

does  not  express  a  desire  to  change  the  function  of 
the  hospital,  but  to  develop  it;  not  to  insist  that 
the  tools  be  rejected,  but  that  they  be  more  exactly 
fitted  to  the  work  they  are  called  upon  to  do. 

HOSPITAL  SOCIAL  SERVICE  AND  MEDICINE. 
For  a  long  time  skilled  hospital  physicians,  es- 
pecially dispensary  physicians,  have  seen  that 
many  of  their  painstaking  efforts  have  been  futile 
so  far  as  their  real  value  to  the  patients  was  con- 
cerned. Hospital  social  service  has  presented  it- 
self to  them  as  an  aid  in  so  rounding  out  their  work 
with  the  individual  patient  as  to  justify  the  effort 
and  expense  involved  in  medical  treatment.  The 
natural  result  is  going  to  be  an  embodiment  in  the 
technique  of  medicine  itself  of  many  of  the  meth- 
ods characteristic  of  the  best  social  work.  The 
hospital  physician  will  find  it  more  and  more  im- 
possible to  ignore  the  psychological  and  social 
elements  of  his  patient's  troubles.  He  recognizes 
that  he  cannot  treat  a  disease  of  the  kidneys  with- 
out reference  to  the  heart,  the 'digestion,  and  the 
nervous  system.  He  is  beginning  to  feel  that  he 
cannot  treat  headache  without  a  knowledge  of  a 
man's  work,  home  conditions,  sleeping  habits,  and 
economic  anxieties.  He  will  not  become  a  social 
worker  in  the  technical  sense,  but  he  will  use 
the  methods  of  this  closely  related  profession 
more  and  more  freely  as  he  learns  their  medical 
value.  Even  if  we  never  get  any  further  than 
where  we  now  are,  hospital  social  work  may  feel 
that  it  has  at  least  thrown  a  new  light  upon  the 


FUTURE   OF   HOSPITAL   SOCIAL   SERVICE 

practice  of  medicine  in  hospitals  and  dispensaries, 
and  brought  into  the  foreground  some  facts  vital 
to  medical  knowledge  that  were  in  semi-darkness. 

Hospital  social  service  has  come  in  on  such  a 
high  wave  of  enthusiasm  that  it  has  run  some 
dangers.  To  its  friends  it  seemed  to  embody  so 
vital  a  principle,  to  be  so  appealing  and  so  practi- 
cal, that  they  felt  no  necessity  of  its  advancing 
cautiously  and  justifying  each  step  of  the  way. 
Some  of  the  most  helpful  friends  of  social  service 
have  been  those  who  at  first  were  skeptical  about 
its  value. 

The  conservatism  of  medicine  is  its  protec- 
tion against  quackery.  Before  it  can  be  generally 
accepted  hospital  social  service  must  prove  that 
it  is  neither  a  medical  nor  a  social  fraud.  It 
should  not  pretend  to  be  the  cure-all  nostrum  that 
introduces  human  feeling  into  the  "heartless" 
clinic,  but  should  recognize  that  kindly  interest  in 
human  beings  is  nothing  new  to  the  medical  pro- 
fession. Hospital  social  service  extends  the  hu- 
manity of  the  hospital,  but  cannot  boast  of  ini- 
tiating it.  Neither  should  it  feel  that  a  social 
diagnosis  is  more  important  than  a  medical,  but 
that  it  is  supplementary  and  helps  the  doctor  form 
a  plan  of  treatment  within  the  range  of  the  pa- 
tient's possibilities.  What  it  may  rightly  take 
pride  in  is  the  privilege  accorded  it  of  forming  out 
of  elements  in  the  two  great  professions  of  medi- 
cine and  sociology,  a  new  profession.  This  is  a 
pride,  however,  that  conduces  to  humility  rather 
than  to  vainglory. 

203 


SOCIAL  WORK  IN  HOSPITALS 

HOSPITAL  SOCIAL  SERVICE  AND  MEDICAL  SO- 
CIOLOGY. Medical  sociology,  the  science  of  the 
interplay  of  medical  and  social  elements  in  human 
society,  is  looking  for  laboratories  in  which  to  study 
its  problems.  The  study  of  occupational  diseases, 
alcoholism,  blindness,  tuberculosis,  and  immoral- 
ity, is  rapidly  engaging  the  attention  of  medical 
and  social  experts,  who  are  looking  for  the  best 
sources  of  material  and  the  most  suitable  condi- 
tions under  which  to  make  their  investigations. 
Hospital  social  service  departments  offer  ideal 
opportunities  for  the  conduct  of  medical-social 
clinics.  Patients  file  by,  day  after  day,  victims 
of  all  the  tragedies  of  solitary  struggle  and  of 
community  life.  Social  workers  chafe  at  the  fu- 
tility of  their  efforts  at  repair,  and  long  for  a  cam- 
paign of  prevention.  They  soon  realize,  however, 
that  the  task  of  prevention  is  more  complex  and 
involved  than  medical-social  treatment. 

Campaigns  of  education,  which  are  the  chief 
weapons  of  prevention,  must  be  preceded  by  care- 
ful analysis  of  the  various  contributory  causes,  and 
of  the  possibilities  for  effecting  a  change.  Here  is 
the  work  of  the  expert  in  medical  sociology.  Social 
service  departments  can  perform  a  great  function 
by  serving  as  laboratories  for  the  students  who 
try  to  "learn  of  life  from  our  mortality."  The 
Social  Service  Department  at  the  Massachusetts 
General  Hospital  has  attempted  to  answer  by 
careful  investigation  the  question,  "Why  do  work- 
ing girls  become  so  debilitated  that  they  are  forced 
204 


FUTURE   OF   HOSPITAL   SOCIAL   SERVICE 

to  come  to  the  hospital?"*  The  Boston  Dispen- 
sary has  established  as  a  member  of  its  social  ser- 
vice staff,  a  medical-social  investigator  who  will 
serve  throughout  the  year. 

All  these  signs  point  to  prevention  as  fundamen- 
tal in  constructive  medical  or  social  work.  Of 
course  shiftlessness,  broken  legs,  and  sick  babies 
will  still  be  with  us  even  after  the  elimination  of 
hookworm  disease,  the  control  of  dangers  from  in- 
dustrial accidents,  and  the  extended  education  for 
motherhood.  Although  we  cannot  hope  that  pre- 
ventive measures  will  wipe  out  all  our  medical- 
social  problems,  we  can  be  sure  that  education 
will  slowly  and  surely  remove  many  of  the  causes 
of  physical  distress  as  we  see  them  today.  To  have 
a  small  share  in  this  service  is  the  privilege  of  the 
hospital  social  worker,  for  through  the  education  of 
the  individual  patient  and  the  recognition  of  the 
significance  of  the  day's  work  she  may  find  large 
opportunities  to  make  her  contribution.  A  valu- 
able research  into  social  conditions  surrounding 
cases  of  ophthalmia  neonatorum  was  conducted 
by  Miss  Catherine  Brannick,  Social  Worker  of 
the  Massachusetts  Charitable  Eye  and  Ear  In- 
firmary of  Boston;  the  results  were  published  in 
her  Second  Annual  Report  (1910).  The  facts 
which  she  presents  constitute  a  very  legitimate 
appeal  for  the  helpless  baby,  facing  the  possibility 
of  blindness,  and  suggest  innumerable  possibilities 

*  See  Massachusetts  General  Hospital,  Social  Service  Department. 
Sixth  Annual  Report,  1911. 

205 


SOCIAL   WORK    IN    HOSPITALS 

for  the  hospital  in  bringing  vividly  to  the  atten- 
tion of  the  public  the  social  burden  of  disease. 

Occupational  diseases  are  beginning  to  attract 
to  an  increasing  extent  the  attention  of  physicians 
and  sociologists  in  the  United  States.  Some  in- 
vestigations of  occupational  diseases  are  best 
made  in  the  factory  or  work-shop,  but  other  op- 
portunities for  such  studies  should  not  be  over- 
looked. The  hospital  and  dispensary  are  con- 
tinually caring  for  victims  of  industry  without  any 
consciousness  of  the  significance  of  the  patient's 
diseases.  In  a  Symposium  on  Industrial  Diseases 
in  June,  1912,  Dr.  W.  Oilman  Thompson  pointed 
out  some  of  the  opportunities  in  hospitals  and  dis- 
pensaries to  study  such  diseases.  He  also  pre- 
sented a  classification  of  occupational  diseases  and 
made  suggestions  as  to  the  possible  function  of 
hospital  social  workers  as  agents  in  these  studies.* 

Dr.  Richard  C.  Cabot  also  has  indicated  the 
chances  which  hospitals  and  dispensary  clinics  offer 
for  the  study  of  industrial  diseases.!  He  argued 
that  the  position  of  hospital  physicians  is  strategic 
for  an  unbiased  view  of  medical-social  conditions. 
So  many  incidental  products  of  industry  pass 
through  the  hospital  that  the  socially-minded 
physician  can  find  abundant  material  close  at 
hand.  When  he  realizes  his  opportunity,  he  can 

*  Thompson,  W.  Oilman:  Classification  of  Occupational  Diseases. 
American  Labor  Legislation  Review,  June  12,  Vol.  2,  No.  2,  pp.  185-191. 

t  Cabot,  Richard  C.:  The  Function  of  Hospitals  and  Clinics  in 
the  Prevention  of  Industrial  Diseases.     American  Labor  Legislation 
Review,  June  i,  1912,  Vol.  2,  pp.  293-296. 
206 


FUTURE    OF    HOSPITAL    SOCIAL    SERVICE 

do  a  great  service.  The  thoroughly  trained  hospi- 
tal social  worker  as  agent  of  the  socially-conscious 
hospital,  reflecting  the  scientific  attitude  of  the 
medical  profession  and  bringing  to  medical  con- 
ditions the  special  knowledge  of  the  social  worker, 
has  opportunities  for  research  which  have  not 
yet  been  fully  appreciated. 

Beginnings  have  been  made  in  the  study  of  in- 
dustrial diseases  coming  to  the  knowledge  of  the 
Social  Service  Department  of  the  Massachusetts 
General  Hospital.  Patients  suffering  from  lead 
poisoning  who  had  been  treated  at  the  hospital  are 
being  sought  out  by  medical-social  workers  to  as- 
certain what  the  definite  occupation  was  and  the 
mode  of  poisoning.  It  was  found  that  among  the 
patients  treated  during  a  period  of  five  years,  147 
cases  of  plumbism  were  recorded.  A  preliminary 
study  of  the  medical  records  showed  the  lack  of 
important  social  facts  in  these  cases,  but  also  in- 
dicated the  unusual  opportunity  that  medical  in- 
stitutions have  for  taking  account  of  the  social  im- 
portance of  cases  treated.  If  accurate  description 
of  all  occupational  processes  could  be  obtained  in 
cases  of  lead  poisoning  the  hospitals  could  offer 
valuable  material  to  those  who  are  seeking  for 
better  labor  legislation  and  enforcement  of  indus- 
trial hygiene.  "Laborer"  means  nothing  to  a 
physician  who  is  examining  a  specimen  of  blood 
and  finds  a  "marked  stippling"  (suggesting  lead 
poisoning),  but  when  he  learns  that  this  laborer  is  a 
sealer  of  paint  in  the  hold  of  a  ship  in  the  navy 
207 


SOCIAL   WORK    IN    HOSPITALS 

yard,  he  has  new  evidence  as  a  basis  for  his  diag- 
nosis. Also  a  consciousness  on  the  part  of  physi- 
cians of  the  relation  between  the  patient's  diagno- 
sis and  his  occupation  might  make  it  probable  that 
no  patient  treated  for  lead  poisoning  would  leave 
the  hospital  without  knowing  why  he  was  sick. 

In  research  as  in  all  other  aspects  of  hospital 
social  service  the  foundation  of  careful  medical 
work  is  essential.  With  this  as  a  basis,  the  hos- 
pital social  worker  who  in  the  spirit  of  scientific 
medicine  seeks  for  the  social  backgrounds  of 
disease  should  be  able  to  help  considerably  in  the 
progress  of  medical  sociology. 

HOSPITAL  SOCIAL  SERVICE  AND  THE  MEDICAL 
STUDENT.  All  the  progressive  movements  for 
public  health  and  social  welfare  need  the  socially- 
minded  physician.  Such  doctors  as  Henry  B. 
Favill,  Prince  A.  Morrow,  Henry  J.  Gerstenberger, 
and  David  L.  Edsall  are  the  mainstay  of  the  cam- 
paigns against  tuberculosis,  venereal  disease,  in- 
fant mortality,  and  occupational  disease.  The 
social-mindedness  of  doctors,  however,  is  not  given 
them  by  their  medical  training.  Rather  do  they 
get  it,  if  at  all,  through  their  natural  interests  and 
through  the  conviction,  forced  upon  them  by  years 
of  medical  practice,  that  medicine  and  sociology 
cannot  be  divorced.  Society  should  not  have  to 
depend  upon  the  chance  production  of  this  most 
valuable  type  of  physician;  the  medical  schools 
should  assume  the  responsibility  of  producing 
208 


FUTURE   OF   HOSPITAL   SOCIAL   SERVICE 

them.  Medical  schools  cannot  teach  psychology 
and  sociology,  of  course,  though  they  might  de- 
mand preliminary  training  in  these  subjects  dur- 
ing the  years  of  college  preparation.  But  clinical 
teachers  can  so  bring  out  the  significance  of  social 
facts  in  all  the  cases  which  they  study  with  medical 
students,  that  the  student  is  forced  to  recognize 
the  inseparableness  of  the  medical  and  social  ele- 
ments in  disease. 

Since  he  became  dean  of  the  Indiana  School  of 
Medicine,  Dr.  Charles  P.  Emerson  has  made  a  very 
significant  effort  to  teach  students  the  relation  be- 
tween medical  and  social  conditions.  A  medical 
clinic  held  each  week  in  the  Medical  School  in 
I  ndianapolis  is  followed  by  a  social  conference  which 
is  often  as  interesting  to  the  students  as  any  part 
of  their  technical  training.  The  social  service 
department  of  the  dispensary  in  which  the  medical 
students  have  clinical  experience  is  affiliated  with 
the  department  of  sociology  of  Indiana  Univer- 
sity. Medical  students  offer  their  services  to  the 
social  worker  in  cases  in  which  medical-social 
tangles  need  to  be  followed  and  unraveled.  One 
Tuesday  morning  the  conference  discussed  a  vic- 
tim of  chlorosis,  for  whom  little  was  done  medi- 
cally beyond  the  ordering  of  iron  pills.  The  stu- 
dent who  offered  to  undertake  the  supervision 
of  this  patient's  treatment  found  the  girl  working 
in  a  laundry  where  she  was  standing  all  day  on  a 
wet  floor  and  feeding  wet  clothes  into  the  mangle. 
She  took  a  cold  lunch  to  the  laundry,  and  outside 
14  209 


SOCIAL   WORK    IN    HOSPITALS 

of  working  hours  helped  with  the  housework  at 
home.  She  slept  with  her  grandmother,  who 
had  a  prejudice  against  "night  air." 

The  discussion  of  such  a  case  as  this  impresses 
upon  the  student,  as  no  textbook  can,  the  futility 
of  medical  unrelated  to  social  treatment.  While 
supervising  the  medical  care  of  the  case,  the  stu- 
dent's experience  constantly  teaches  him  the  medi- 
cal and  social  inter-relations  in  the  causation,  the 
prognosis,  and  the  cure  of  disease.* 

Social  service  departments  in  hospitals  or  dis- 
pensaries affiliated  with  medical  schools  have  a 
unique  opportunity  to  bring  clearly  before  stu- 
dents the  inevitable  complexity  of  the  patient's 
physical,  mental,  and  social  conditions.  It  is  im- 
portant to  relate  instruction  in  the  mental  and 
social  elements  of  a  patient's  condition  very 
closely  to  the  clinical  consideration  of  his  dis- 
ease. By  making  use  of  clinical  material  as  an 
avenue  to  a  broadening  of  the  student's  outlook 
on  medicine,  it  is  possible  not  only  to  teach  him 
to  be  a  better  physician  but  also  to  recognize  some 
of  his  own  relations  to  the  community's  health 
agencies.  If  while  he  was  following  the  treatment 
of  a  case  of  typhoid,  he  could  at  the  same  time 
know  the  trail  to  the  source  of  the  patient's  in- 
fection, his  eyes  could  possibly  be  opened  to  the 
importance  of  a  pure  milk  supply  and  some  of  the 
functions  of  the  board  of  health.  Medical-social 
workers  can  do  a  great  service  in  revealing  to 

*  For  list  of  diseases  and  the  social  treatment  which  they  demand, 
see  Appendix,  p.  240. 

210 


FUTURE    OF    HOSPITAL    SOCIAL    SERVICE 

socially-minded  medical  students  the  opportuni- 
ties and  responsibilities  in  their  most  human  pro- 
fession. 

HOSPITAL  SOCIAL  SERVICE  AND  THE  NURSE. 
The  social  worker  in  the  hospital  can  often  bring 
to  the  attention  of  the  pupil  nurses  interesting 
social  facts  about  the  patients  for  whom  they  are 
caring.  She  may  help  the  nurse  to  be  conscious 
of  the  individuality  of  the  patient  in  the  rush  of 
hospital  life,  and  to  keep  clearly  before  her  the 
patient's  need  of  occupation  and  recreation,  the 
anxious  family  outside,  the  employer,  and  the 
many  other  human  aspects  of  her  work. 

Up  to  the  present  time  hospital  social  service 
has  had  little  effect  on  the  training  of  the  nurse. 
She  has  been  disciplined  for  skilled  bedside  care 
of  patients.  Her  hands  have  been  trained  for 
delicate  service  to  suffering  bodies;  her  mind 
taught  to  recognize  general  symptoms  in  the  prog- 
ress of  disease.  The  demand  for  this  type  of  nurse 
will  never  cease.  But  the  field  of  usefulness  for 
women  with  medical  and  nursing  training  has 
greatly  broadened  in  recent  years.  Other  types  of 
nurses  are  also  in  demand  now — nurses  to  serve  in 
various  kinds  of  public  health  work.  The  training 
schools  are  not  fitted  to  prepare  women  for  this 
variety  of  special  functions.  The  great  army  of 
nurses,  who  for  many  years  have  been  serving  in 
such  public  health  movements  as  factory  nursing, 
visiting  nursing,  tuberculosis  campaigns,  insurance 


SOCIAL   WORK    IN    HOSPITALS 

work,  prenatal  work,  the  infant  mortality  fight, 
the  prevention  of  blindness,  and  the  intensive 
health  work  of  social  settlements,  have  had  little 
preparation  for  their  tasks  except  a  general  medi- 
cal training  within  the  hospital  walls.  Individual 
nurses  have  entered  public  health  work  because  of 
their  social  interests.  But  their  special  skill  has 
come  through  experience  in  their  chosen  sphere 
rather  than  in  formal  preparation.  Practical  ex- 
perience should  not  be  underestimated,  but  more 
consistent  training  is  now  in  demand. 

Within  the  last  few  years,  the  schools  of  phil- 
anthropy in  New  York,  Chicago,  St.  Louis,  and 
Boston  have  enrolled  an  increasing  number  of 
nurses  as  pupils.  A  few  schools  for  visiting  nurs- 
ing have  developed,  such  as  those  in  Boston  and 
Cleveland.  Courses  in  public  health  nursing  are 
now  offered  at  the  Teachers  College,  New  York, 
under  the  Department  of  Nursing  and  Health  and 
by  the  Boston  School  for  Social  Workers  in  affili- 
ation with  the  Instructive  District  Nursing  Asso- 
ciation. But  only  a  very  small  proportion  of  the 
nurses  now  in  public  health  work  have  had  the 
advantages  of  any  of  these  courses.  Nor  can 
the  nurses  who  have  had  these  opportunities  be- 
gin to  meet  the  demand  for  socially  trained  nurses. 

The  nurses'  training  schools  have  found  it  im- 
possible to  adapt  the  technical  training  of  the 
nurse  to  the  phenomenal  development  of  the  field 
of  usefulness  now  open  to  her.  Some  of  the  train- 
ing schools,  however,  have  made  it  possible  for 


FUTURE   OF   HOSPITAL   SOCIAL   SERVICE 

the  pupil  nurses  to  leaven  their  three  years  of 
hospital  routine  with  a  short  experience  in  visit- 
ing nursing.  The  object  is  usually  two-fold:  to 
broaden  the  outlook  of  the  nurse  by  bringing  to 
her  attention  the  conditions  under  which  her 
patients  live;  and  to  give  her  an  opportunity  to 
see  the  function  of  the  nurse  in  the  homes  of  those 
who  are  both  sick  and  poor.  In  the  Presbyterian 
Hospital,  New  York,  many  of  the  nurses,  during 
their  third  year,  elect  a  period  of  visiting  nursing 
under  the  direction  of  the  supervisor  of  visiting 
nursing  connected  with  the  hospital.  Other 
training  schools  have  arranged  with  visiting  nurs- 
ing associations  to  give  undergraduates  two  or 
three  months'  experience,  under  the  supervision 
of  the  association. 

In  hospitals  with  well-organized  social  service 
departments,  an  opportunity  might  be  offered  for 
nurses  who  desire  it,  to  secure  experience  in  hos- 
pital social  service.  The  time  that  could  be  al- 
lowed for  such  experience  would  undoubtedly  be 
too  short  for  thorough  training  but  it  would  give 
the  nurses  an  acquaintance  with  the  attractive 
openings  in  this  new  field.  Also,  the  undergraduate 
nurse  might  get  an  insight  into  visiting  nursing, 
school  and  factory  nursing,  baby  hygiene  work, 
tuberculosis,  and  medical  educational  work,  under 
the  guidance  of  the  social  service  department  of  the 
hospital.  Such  experience  could  not  fail  to  broaden 
her  outlook,  whatever  kind  of  nursing  she  does 
after  graduation.  Such  a  curriculum  would  in- 
213 


SOCIAL   WORK    IN    HOSPITALS 

dicate  the  rapidly  developing  fields  of  usefulness 
for  nurses  and  might  attract  to  the  training  schools 
an  increasing  number  of  women  of  superior  ability 
and  education. 

Such  a  plan  of  co-operation  has  been  started 
at  the  Massachusetts  General  Hospital.  Senior 
nurses  who  have  a  special  social  interest  are  per- 
mitted to  have  three  months'  experience  in  the 
social  service  department.  No  nursing  is  done  dur- 
ing that  time,  but  the  nurse  becomes  a  social  stu- 
dent-worker in  the  department,  studies  the  pa- 
tients, and  is  shown  the  close  relation  of  the  medical 
service  that  the  hospital  is  rendering  and  the  efforts 
of  the  social  workers.  One  of  the  pupil  nurses 
who  had  this  experience  testified  that  not  only 
her  social  but  her  medical  knowledge  increased  in 
this  period  because  many  patients  and  diseases 
treated  in  the  out-patient  department  were  not 
admitted  to  the  ward  and  so  never  seen  by  the 
nurses.  The  variety  of  experience  and  the  awaken- 
ing of  the  nurse  to  the  activities  for  social  better- 
ment give  her  not  only  a  glimpse  of  a  new  field 
open  to  her  if  she  feels  called  to  that  type  of  ser- 
vice, but  further  make  her  more  conscious  of  what 
is  going  on  in  the  world  about  her  so  that  "even 
the  newspapers  are  more  interesting." 

HOSPITAL   SOCIAL   SERVICE   AND   THE   SOCIAL 

WORKER.     Possibly   no  one   has   welcomed   the 

hospital  social  worker  more  heartily  than  the  social 

worker  outside  the  hospital.     Except  for  an  oc- 

214 


FUTURE  OF  HOSPITAL  SOCIAL  SERVICE 

casional  fear  that  the  hospital  worker  might  tres- 
pass on  the  province  of  the  other  social  workers, 
there  has  been  a  general  recognition  of  the  open- 
ings in  this  new  field  and  an  appreciation  of 
the  help  which  the  social  worker  within  the  hospi- 
tal might  give  to  those  without.  She  can  interpret 
to  the  worker  outside  the  technical  and  cryptic 
information  given  out  by  the  physicians  about  the 
patients  sent  to  the  dispensary  clinics ;  she  can  also 
advise  the  outside  worker  as  to  the  needs  of  the  pa- 
tients discharged  from  the  wards.  Such  knowledge 
as  she  can  give  is  often  necessary  to  a  constructive 
plan  for  the  man  seeking  charitable  assistance.* 

Acquaintance  with  the  relation  of  disease  to  de- 
pendence is  not  new  to  social  workers,  but  they 
need  much  more  definite  knowledge  of  physical 
conditions.  Also  from  the  doctor  they  have  much 
to  learn  concerning  the  subtler  relations  between 
sociological  and  physical  sufferings.  What  the 
hospital  social  workers  thus  learn  they  can  pass  on 
to  the  social  workers  outside.  Such  an  exchange 
enlarges  the  community's  understanding  of  the  in- 
fluence of  sickness  on  character,  of  the  pathological 
effects  of  fatigue  and  malnutrition,  of  the  prevent- 
ive and  curative  use  of  hygienic  measures,  of  the 
value  of  suitable  diet  and  the  limitations  of  moral 
responsibility  in  the  victims  of  wretched  physique. 
In  the  future  there  will  be  fewer  failures  in  plans 
for  the  socially  afflicted  which  can  be  traced  to 
ignorance  of  the  physical  background. 

*  See  Chapter  IV,  p.  97. 
215 


SOCIAL   WORK    IN    HOSPITALS 

In  some  cases  the  physical  basis,  all  ignored, 
may  be  the  chief  cause  for  the  individual  disaster. 
An  illustration  of  this  truth  is  given  in  the  fourth 
annual  report  of  the  social  work  at  the  Massachu- 
setts Charitable  Eye  and  Ear  Infirmary,  Boston. 
The  report  reads,  "A  man,  forty-eight  years  of 
age,  was  sent  to  us  one  day,  ragged,  emaciated, 
almost  helpless  without  his  glasses,  which  had  been 
broken  a  few  days  before.  His  record  with  the 
public  and  private  charities  of  Boston  and  other 
cities  was  a  very  bad  one:  idleness,  drink,  immor- 
ality, neglect  of  his  children.  The  hospital  found 
a  condition  of  high  myopia,  which  had  been  cor- 
rected only  after  the  man  had  passed  his  twenty- 
fifth  year,  when  he  had  thoroughly  learned  the 
lesson  of  idleness;  the  rest  had  followed  easily. 
All  his  life  he  had  been  handicapped;  in  school, 
when  his  fellow-pupils  who  had  better  vision  left 
him  far  behind;  later,  when  work  was  difficult  to 
find  and,  for  him,  almost  impossible  to  keep;  and 
later  still,  after  glasses  had  been  found  to  help  the 
vision,  by  the  habit  of  idleness  and  its  attendant 
evils  acquired  through  little  fault  of  his  own. 
There  was  no  doubt  about  his  very  bad  record,  but 
the  hospital  finding  left  much  doubt  as  to  his  in- 
dividual responsibility  for  it.  Though  our  report 
could,  of  course,  make  no  difference  in  the  action 
of  any  charitable  society  in  such  a  case,  as  present 
conditions  must  govern  action,  it  would  essen- 
tially change  the  attitude  and  modify  the  message 
to  the  public  in  regard  to  this  physical  misfit." 
216 


FUTURE   OF   HOSPITAL   SOCIAL   SERVICE 

Sometimes  return  to  health  brings  about  trans- 
formations in  character  that  are  unpredictable. 
A  change  of  heart,  no  less  startling  than  conver- 
sion, followed  the  amputation  of  a  foot  which  the 
doctors  had  fought  for  months  to  save.  The  vic- 
tim had  been  irritable,  neglectful  of  his  children, 
and  given  to  drunken  sprees.  Convalescence  after 
the  operation  found  him  changed  to  a  sober,  hard- 
working man. 

Many  years  ago,  Florence  Nightingale  said  that 
there  could  be  no  health  of  the  community  without 
health  of  the  individual.  The  most  fundamental 
means  of  securing  health  for  people  is  education. 
Physicians  are  increasingly  convinced  that  the  best 
relationship  for  treatment  of  a  patient  is  one  of 
frankness  and  mutual  trust.  The  patient  with 
tuberculosis  now  knows  his  condition  and  becomes 
a  partner  in  treatment.  There  is  gradually  de- 
veloping a  belief  that  the  best  remedy  for  the  little 
knowledge  that  is  a  dangerous  thing  is  more  knowl- 
edge. Broad-minded  men  and  women  in  the  pro- 
fessions of  medicine  and  social  work  have  seen  that 
dissemination  of  medical  knowledge  is  on  the  whole 
a  safeguard,  not  a  danger;  and  that  education  in 
physiology  and  hygiene  is  among  the  most  im- 
portant factors  for  community  health. 

Hospital  social  service  offers  one  of  the  best 
opportunities  for  general  and  individual  education 
in  hygiene  and  right  living.  The  opportunity  to 
interpret  daily  physical  facts  to  social  workers 
outside  the  hospital,  to  point  out  social  facts  to 
217 


SOCIAL   WORK    IN    HOSPITALS 

physicians,  and  to  explain  simple  laws  of  whole- 
some living  to  patients,  makes  the  hospital  social 
worker  rejoice  that  any  knowledge  she  may  have 
is  not  held  secret  in  her  profession.  Her  greatest 
privilege  is  to  pass  it  on  truthfully  and  generously 
to  others. 


218 


APPENDIX 
FORMS  AND  FACSIMILES 


fflaHBart|uarttfl  (flrttrrnl  j%a0pttal—  £orial  ^rrmrr  Department 


*  M.  W. 

Nationality 
Birthplace 

Previous  medical  treatment  (place)  :  (When) 

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BOSTON  DISPENSARY 


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FORM  USED  BY  AGENCIES   REFERRING  PATIENTS  TO  DISPENSARIES  FOR  REPORT  OF 

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226 


HOSPITAL   UNIVERSITY 

OF  PENNSYLVANIA 

Social  Service  Department 

Name                                               Age       S.  M.  W.  D.    Case  No. 

Date  of  Birth 

Place 

Nationality 

Address 

Church 

Former  Address                    Citizen 

How  long  in  U.  S. 

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Reason  Referred 

RECORD  FORM  USED  BY  SOCIAL  SERVICE  DEPARTMENT,  UNIVERSITY  OF 
PENNSYLVANIA  HOSPITAL 

227 


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Social  Diagnosis 

RECORD  FORM  USED  BY  SOCIAL  SERVICE  DEPARTMENT,  MASSACHUSETTS  GENERAL 
HOSPITAL 

330 


location     Ktf^LxO      . 
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RECORD   FORM   USED  FOR  TUBERCULAR   PATIENTS.     SOCIAL  SERVICE   DEPARTMENT, 
BOSTON  DISPENSARY 


231 


D-  W^     C     /7/z  BOSTON    DISPENSARY, 


RECORD  FORM  USED  FOR  ALL  MEDICAL  HISTORIES  IN  THE  CHILDREN'S  CLINIC,  BOSTON 
DISPENSARY 


232 


"»">«•    Mary----  Hr»pit»iNo   857 

*««      8i  months  o«.Pni«i  NO  25766 

Knhplur  s^jji  s.rvkt  No  £379 

P3w.nl.- N.me  George  &  Fanny 

Pwtntv  A<birr«       23  Inglesida  Street, Roxbury 

Admi««<«Dau.       March  18.    1912  Diwh^e  D««      Uarch  25.    1912 

r>iapuv»i«  Burn  on  foot  Diverge  Diipiosi»    Cured 


(Family.  Social  and  PerMMu!  History,  Phytical  Ex    MO 

FAMILY  HISTORY:   Father  alive  and  well;   mother,   phlebitis  Binoe  laat  aummer, 
and  nervous  prostration.      Miscarriage  due  to  hard  work.      Twins  died  at 
birth.     One  brother  and   three  sisters  alive  and  well. 

SOCIAL  HISTORY;   Family  are  Irish  Catholics  who  came  from  II— 2     ago.     Father 
was   a  councilman  and   ran  email   etore;f ailed   in  Nov. 1911.     Wife  then  ill   in 
hospital  when  last  child  was  born.      In  January  parents  broke  up  home,    sent 
older  children  to  relatives  and     placed    baby   in  St. Vary's   Infant  Asylum, 
where   it  later  was  boarded   out.     Parents  secured  position   temporarily  as 
house-keeper  for  a  family   in  D--.      They  have  their  board   (and   that  is  all) 
In  return  tor   service  given.      As so. Charities  interested   in  helping  family 
and   will  place  baby  to    board  when  discharged  from  the  Hospital.     Mrs., at 
present,    being  treated   in  Diep.      Diagnosis.  ?   Specific.      Family   also  known 
to   A.  C.    of  D.      Family  unable  to  pay  hospital   fee. 

PAST  HISTORY;    Normal   delivery;   8  mos.    gestation.      Ophthalmia  at  birth. 
Breast  for  3  weeks;    since  then  has  been   in   various  institutions  and  boarded 
out..     Feedings  while  boarded,   unknown.      Has  had   some  cough.      Bowels  regular. 
Bats  well.      Does  not  sleep  well.      Has  been  fed   from  our  O.P.D.   past  two 
weeks. 

PRESENT  ILLNESS;   Mother  burned  baby's  foot  with  hot  iron  while  trying  to 
warm  It;   burned  16  days  ago.     Burn  has  not  don*  w«U  on  boa*   treatment.     Hat 
had  Hood's   3  6.5  1.5  B.S..    75  LW  20#  ra&c .   F7  02. 7.     Has  vomited   a  little 
After  feeding 

PHYSICAL  EXAMINATION: 

5ITIOH:   Medical:   Mary  discharged   to  Uaes.   Babies1   Hospital   for 
pending  parents'    arrangement  for   housekeeping. 

Social:  Referred  to  Aaeo.Chari  ties,  dist.4,  to  aid  fam- 
ily, wno  sent  mother  and  children  to  parents  in  Maine  for  3  month*.  Father 
started  a  store  and  is  getting  on. 


WARD  RECORD.    CHILDREN'S  HOSPITAL,  BOSTON  DISPENSARY 


233 


FACSIMILES  OF  REFERENCE  SLIPS  USED  BY  PHYSICIANS  WHEN  REFERRING  PATIENTS 

TO  A  SOCIAL  SERVICE  DEPARTMENT 

234 


Massachusetts  General  Hospital* 

Leave  on  Admitting  Physician's  desk. 


To Executive  Assistant 

)f  Ward      fa (Service) 

is  referred  to  you  for 

(Underline  th«  following  to  be  looked  up) 

Removal  to  another  institution 
Investigation  of  home  conditions. 

"             "    financial  condition. 
Apparatus. 
Ward  visiting  for 


Diagnosis ... T~.. tir&^r^...fo^^^  <-n^<_<^    i 

Prognosis J~^>^&-^~ 

Future  treatment  9 

How  long  will  aid  be  required • 

Patient  will  be  ready  for  discharge £b*....£?±^. 

(Probable  date) 

JRemarks 


x____^/7 


.House  Pupil. 

FACSIMILE  OF  REFERENCE  SLIP  USED  BY  PHYSICIAN  REFERRING  PATIENT  TO  A  SOCIAL 

WORKER 

235 


BOSTON  DISPENSARY 

P«<e  1  Record  No. 

NAME  Age  8.M.W  D.    Date 

Address  Color  B.  D  No. 


Clinic 


(Old 


<D»U»  and  climes 
Nationality  Birthplace 

Names  of  parents  (or  husband) 
How  long  resident  of  U.  8.  A. 
How  long  resident  of  Boston  Yra. 

OCCUPATION  Earnings 

Position 

Where  employed 

How  long  in  present  occupation  .  Previous  occupations 

NARRATIVE  ^a 


Pttient'i  attitude  towsid 


O.  P.  D.  (When  sad  foe  wh*t) 

ftopiul  (Ditto) 

Priv.u  Doctor  (0  P  or  Spl't) 


FORM   USED   FOR   STUDY  OF  GROUP  OF  PATIENTS  COMING  TO  THE  BOSTON   DIS- 
PENSARY (FACE) 

236 


BOSTON  DISPENSARY 

Page  2 

HOME    H.  or  T.  Floor  F.  or  R. 

Light  Air 

Sunlight 
Housing  summary 


Occupants 
Tidy 
Windows  face  on 


Rent,  $ 
Sanitation 


per  wk. 


Occupation  and  Earnings 


CHARITY    Were  B.  D.  fees  paid 
Interested  agencies 


DIAGNOSIS  as  on  record 
Prescription  as  on  record 
Treatment  program  as  on  record 

Medical  outcome  as  shown  on  record 


Known  C.  E.  of  I. 


Referred  to  S.  S. 


FORM  USED  FOR  STUDY  OF 


GROUP  OF  PATIENTS  COMING  TO  THE    BOSTON   DIS- 
PENSARY (REVERSE) 

237 


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FORM  USED  IN  EFFICIENCY  TEST  OF  DISPENSARY  TREATMENT,  BOSTON  DISPENSARY 

A-.fi 


SURVEY— CHILDREN'S  CLINIC 

Name  Age  -Sex  O.  P   D.  No. 

Residence  >         Birthplace 

Diagnoses  (dates,  il  noted) 

Date  of  ist  visit  (Children's  Clinic)  Date  of  latest  visit  (Ch.  Cl.)         Total  No.  v.sits 

Ref.  from  Clinic  Date  No.  visits 


Other  clinics  dealing  with  child  April  ist 

August  ist 

Condition  &  noted  on  latest  visit  to  Ch.  Rm.   (Rpt.  to  AU*.  ist) 

LABORATORY  TF.ST- 


JUI.TS  UNSATISFACTORY 

Urine  analys 

Pt.  attending  regularly,  but  no  results 

••  (ailing  to  attend  ^ 

Any  note  on  record  of  advice  to  return  ? 


Stool 

Wasserma 


Treatment  lollowed  :  Pt.  improved 

Vaginal  Smear 

••    cured 

Cases  pending,  Aug.  ist 

Pt.  ref.  to  House  Date  Diag  Cond.  on  disch. 

Asked  to  rpt.  at  O.  P.  D.  ?  Reported  ?  Date 

Referred  to  other  institution 
Social  Record 

FORM  USED  FOR  SURVEY  OF  MEDICAL  RECORDS  OF  CHILDREN'S  CLINIC,  MASSACHUSETI 
GENERAL  HOSPITAL 


239 


DISEASES  and  the  SOCIAL  TREATMENT 
Which  They  Demand. 


! 
1 

** 

fi 

Prevention  of  Con. 
tagion  and  Discovery 
of  Cases  In  House. 

Advice  and  Guidance 
in  Plan  and  Place  of 
Treatment,  Including 
Institutions. 

Help  in  Finding  or 
Clianging  Wort. 

Persuasion, 
Encouragement, 
Consolation, 
Training. 

Nutrition  and 
Hygiene  of  Person 
andHome. 

? 

3 

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v 

t 
f 

+ 

. 

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4- 

4 

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4- 

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4- 

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4- 

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4 

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+ 

4 

4 

Pediculosis,    Scabies,    Favus    (con- 

4- 
+ 
4 

4- 
4- 
4- 

4 

* 
-h 

Industrial  Diseases  and  Neuroses.... 

4 

4 

- 

+ 

+ 

• 

+ 
4- 

4 
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4- 

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4- 

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*Of  Special  Importance                 f  Sometimes.                   J  In  Vaginitis  Especially 
18 

LIST  OF   DISEASES  AND  SOCIAL  TREATMENT  WHICH  THEY   DEMAND 

From  7th  Annual  Report,  Social  Service  Dept.,  Mass.  General  Hospital 
240 


INDEX 


16 


INDEX 


ADMISSION  DESK.  See  Selection 
of  Cases 

AGENTS.    See  Social  A  gents 

ALCOHOLISM.  See  Medical-Social 
Problems 

ALMSHOUSE  CARE.  See  Insti- 
tutional Care 

ASSOCIATED  CHARITIES,  Bos- 
ton, 58;  confidential  ex- 
change of,  134-135 


BACKGROUND.  See  Hospital 
Background 

BALTIMORE  CHARITY  ORGANIZA- 
TION SOCIETY.  See  Johns 
Hopkins  University 

BALTIMORE  CHILDREN'S  Am 
SOCIETY:  illegitimate  chil- 
dren cared  for  by,  56 

BASIS  OF  TREATMENT.  See 
Treatment 

BEGINNINGS  OF  HOSPITAL  SOCIAL 
SERVICE.  See  Hospital 
Social  Service 

BELLEVUE  HOSPITAL,  New  York: 
organization  of  social  service 
bureau,  161;  psychopathic 
ward,  65;  volunteer  work- 
ers, 194;  would-be  suicides 
cared  for,  73 

BOOTH'S  "  Life  and  Labor  of  the 
People  of  London,"  129 

BOSTON:  school  for  visiting 
nursing,  212;  social  service 


students  assigned  to  hospital 
work  in,  198,  199.  See  also 
Associated  Cliarities  of  Bos- 
ton 

BOSTON  CHILDREN'S  AID  SO- 
CIETY: illegitimate  children 
cared  for  by,  56,  57;  monthly 
reports  of,  concerning  un- 
married mothers,  57,  58, 
59,6° 

BOSTON  CHILDREN'S  HOSPITAL: 
family  unit  basis  of  record     y" 
at,  146 

BOSTON  DISPENSARY:  analysis 
of  patients,  129,  130;  chil- 
dren's hospital,  discharge 
slips  and  records,  158,  170; 
classification  of  economic 
condition  of  patients,  129; 
co-operation  between  doctor 
and  social  worker  in  chil- 
dren's hospital,  170;  co- 
operative work  in  syphilis 
cases,  61-64;  investigations  / 
of  medical-social  worker,  Y 
168-170;  medical  record  , 
supplemented  by  social  facts,  V 
i57>  *58;  medical-social  in- 
vestigator, 205 ;  medical- 
social  study  of  new  patients, 
171-174;  organization  of 
social  service  department, 
160-161;  School  for  Social 
Workers,  practical  course  in, 
109;  social  service  survey, 
176,  177;  social  worker  in 
the  clinics,  65, 170;  study  of 
gonorrheal  vaginitis,  151; 
survey  of  cases  of  gonorrhea, 
103 


243 


INDEX 


BOSTON  SCHOOL  FOR  SOCIAL 
WORKERS:  hospital  social 
service  course  at,  199;  nurses 
as  pupils  in,  212 

BRANNICK,  CATHERINE,  205 

BUFFALO  CHILDREN'S  HOSPITAL: 
discharge  slips  at,  signed  by 
social  service  worker,  170 

BUFFALO  GENERAL  HOSPITAL: 
organization  of  social  service 
department,  161 

BUREAU  FOR  THE  HANDICAPPED. 
See  New  York  Charity  Or- 
ganization Society 

BURLEIGH,  EDITH  N.,  68,  69,  71, 
72 

BYINGTON,  MARGARET  F.:  The 
Confidential  Exchange,  a 
form  of  Social  Co-operation, 
134;  What  Social  Workers 
should  Know  about  Their 
Own  Community,  125 


CABOT,  DR.  RICHARD  C.,  viii,  15, 
123,  206;  The  Function  of 
Hospitals  and  Clinics  in  the 
Prevention  of  Industrial 
Diseases,  206 

CAMBRIDGE  HOSPITAL:  selection 
of  patients  requiring  care, 
165 

CANNON,  CORNELIA  JAMES,  viii 

CASES:  classification  of,  for 
medical-social  service,  171- 
173.  See  also  Selection  of 
Cases 

CASES  CITED:  chronic,  hernia 
and  alcohol,  47,  leprous  exile, 
49,  saved  from  almshouse 
care,  46;  condition  of  high 
myopia,  116;  confidential 
exchange,  value  of,  shown, 


135-137;  convalescent  home 
habit,  43 ;  debilitated  seven- 
teen-year-old shop  girl,  44; 
deserted  wife,  113-114; 
feeble-minded  woman  with 
gonorrhea,  75-76;  handi- 
capped boys,  90,  92,  94; 
handicapped  girl,  89;  in- 
capacitated by  loss  of  habit 
of  application,  91-92;  insane 
Hebrew  boy,  66-68;  Italian 
with  disease  of  eyes,  138- 
140;  lead  poisoning,  113; 
man  with  Pott's  disease, 
97-98;  medical-social  confer- 
ence, discussion  of  chlorosis 
case,  209-210;  mental  obses- 
sion of  patient  furnished  car- 
fares, 121;  neurasthenic  pa- 
tients, 70,  71-72;  pernicious 
anemia,  4;  poliomyelitis  vic- 
tim and  family,  122;  records  / 
incorrect  because  of  mis-  v 
representations,  148-149; 
relief  for  boy  working  in 
shoe  shop,  84-85,  of  patient 
with  stomach  ulcer,  82, 
private  patient  contributes 
towards,  82-83,  summer 
resident  given,  83,  84;  sca- 
bies, 104;  social  need  of  well- 
dressed  shown,  1 66;  stam- 
mering girl,  116-117;  sui- 
cidal immigrant  woman,  73- 
75;  syphilitic  girl,  62;  syph- 
ilitic parents  and  baby,  61; 
syphilitic  widow,  62,  sent  to 
almshouse,  63;  syphilitic 
wife  of  paralytic,  63;  tonic 
ineffective  because  of  pov- 
erty, 4;  tuberculous,  ad- 
vanced, co-operative,  37, 
fear  of  hospitals  overcome, 
118,  foreign  (Greek),  38, 
39,  foreign  (Irish) ,  48,  incip- 
ient, non-co-operative,  36; 
unmarried  mother,  feeble- 
minded, 53;  unmarried 
mothers,  monthly  reports  of 
Children's  Aid  Society  con- 


244 


INDEX 


cerning,  57,  58,  59,  60; 
widow  and  six  children,  98- 
99,  100,  101,  102;  widow 
with  failing  eyesight,  167, 
168 

CHARACTER:  effect  of  physical 
betterment  on,  216,  217 

CHARITIES.     See  Social  Agencies 

CHARITY  ORGANIZATION  SOCIETY. 
See  New  York  Charity  Or- 
ganization Society 

CHICAGO:  nurses  as  pupils  in 
school  of  philanthropy  in, 
212;  social  service  students 
assigned  to  hospital  work  in, 
198 

CHILDREN'S  AID  SOCIETIES.  See 
Baltimore;  Boston;  Phila- 
delphia 

CHILDREN'S  HOSPITAL.  See 
Boston  Children's  Hospital; 
Boston  Dispensary 

CHRONIC  DISEASE  VICTIMS.  See 
Medical-Social  Problems 

CHURCH:  service  of,  to  sick,  6-7. 
See  also  Workers,  Religious 

CLEVELAND,  Ohio:  school  for 
visiting  nursing  in,  212. 
See  Lakeside  Hospital 

COMMUNITY'S  RESOURCES:  cata- 
logue of,  125,  130-132; 
knowledge  of,  requisite  of 
social  worker,  186.  See  also 
Confidential  Exchange;  So- 
cial Agencies 

CONFERENCES:  a  co-operative 
method,  140 

CONFIDENTIAL  EXCHANGE:  of 
Associated  Charities  in  Bos- 
ton, 134-135;  use  and  value 


of,  134-138.  See  also  Com- 
munity's Resources;  Social 
Agencies 

CONVALESCENTS.  See  Medical- 
Social  Problems 

CO-OPERATION:  between  social 
service  department  and  skin 
clinic  of  Boston  Dispensary, 
in  syphilitic  cases,  61;  cata- 
logue of  city's  resources 
valuable  in,  130,  131,  132; 
confidential  exchange  valu- 
able in,  134,  135,  136,  137, 
138;  effective,  of  social 
agencies,  measure  of  com- 
munity's strength,  125,  126, 
effectiveness  of  cordial;  138; 
in  relief  work  strengthens 
vital  ties,  84;  in  tuberculo- 
sis, 36,  37,  40,  42;  misunder- 
standings destructive  of,  138; 
more  than  responsiveness, 
107;  necessary  to  make 
social  service  integral  part 
of  hospital,  186,  187;  neces- 
sity for,  in  cases  of  un- 
married mothers,  54;  neces- 
sity for,  in  chronic  cases,  48 ; 
of  family  in  plan  of  treat- 
ment, 116,  117,  118,  122; 
of  patient  in  plan  of  treat- 
ment, 107,  108,  109,  117, 
118;  physical  trouble 
secures,  117;  opportunity 
of  hospital  social  worker 
to  encourage,  127;  value 
of,  in  medical-social  re- 
search, 151,  152,  153;  value 
of,  recognized  in  social- 
educational  progress,  126. 
See  also  Working  Together 

CO-OPERATIVE:  conferences  be- 
tween expert  social  workers, 
method,  140;  non-co-opera- 
tive patient,  36 

CORNELL  UNIVERSITY  MEDICAL 
SCHOOL,  158 


245 


INDEX 


DAVIS,  DR.  MICHAEL  M.,  Jr.: 
Efficiency  Tests  of  Out- 
patient Work,  130;  Social 
Aspects  of  a  Medical  In- 
stitution, 171;  The  Effi- 
ciency of  Out-patient  Work, 
103 

DEBILITATION:  study  of,  at 
Massachusetts  General  Hos- 
pital, 204,  205 

DEFECTIVE  CHILDREN.  See  Medi- 
cal-Social Problems,  Feeble- 
minded; Mentally  Defective 
Children 

DEFECTIVES,  MENTAL.  See  Medi- 
cal-Social Problems,  Feeble- 
minded 

DEVINE,  EDWARD  T.,  2;  Misery 
and  its  Causes,  2 

DISEASE:  attendant  of  ignorance, 
neglect,  or  immorality,  108, 
109;  lessening  of,  important 
for  social  progress,  2;  social 
distress  cause  and  result  of, 
a,  23,  27,  28,  29,  215,  216 

DISPENSARY:  cause  of  inef- 
ficiency in  work  of,  23,  29; 
constriction  of  field  of  at- 
tention in,  31,  32;  initial 
social  service  in,  15;  limi- 
tations of  time  in,  31;  rem- 
edy for  inefficiency  in  work 
of,  29.  See  also  Hospital 
Social  Service 

DOCK,  LAVINIA  L.,  AND  NUTTING, 
M.  ADELAIDE:  A  History 
of  Nursing,  19 

DOCTORS.  See  Hospital  Social 
Service  and  the  Medical  Stu- 
dent; Medical  Workers 

DRUG  VICTIMS.  See  Medical- 
Social  Problems 


EDSALL,  DR.  DAVID  L.,  208 

EMERGENCY  SOCIAL  SERVICE, 
119-120 

EMERSON,  DR.  CHARLES  P.,  13- 
15,  198,  209;  a  Social  Ser- 
vice Department  of  a  Gen- 
eral Hospital,  13 

EMPLOYMENT.  See  Medical-Social 
Service  Problems,  Handi- 
capped 

ENGLAND:  charitable  organiza- 
tions in,  n;  Howard's 
report  of  prison  and  hospital 
conditions  in,  18;  lady 
almoners  in  London  hos- 
pitals, 7-11,  165;  relation 
of  hospitals  in,  to  charitable 
organizations,  10;  society 
for  after  care  of  the  insane, 
7-8 


FALL  RIVER.  See  Union  Hos- 
pital of  Fall  River 

FAMILY  OR  COMMUNITY  GROUP 
affected  by  one  member,  16 

FAVILL,  DR.  HENRY  B.,  208 

FEEBLE-MINDED.  See  Medical- 
Social  Problems 

FERNALD,  DR.  WALTER  E.: 
The  Burden  of  Feeble- 
mindedness, 78 

FLIEDNERS  OF  KAISERSWERTH, 
18 

FRANCE:  Howard's  report  of 
prison  and  hospital  con- 
ditions in,  18 

FUTURE  OF  HOSPITAL  SOCIAL 
SERVICE,  THE,  200-218 


GERSTENBERGER, 
J.,  208 


DR.    HENRY 


246 


INDEX 

GODDARD,     HENRY     H.:      The 

HOSPITAL    PATIENTS:     individ- 

Kallikak Family,  53 

uality  of,  29,  30;    point  of 

GONORRHEA:  survey  of  cases  of, 
at  Boston  Dispensary,  103; 
vaginitis,         medical-social 
study  of,  151 

view  of,  26,  27;  position  of, 
26,  27;  social  survey  of,  128, 
129;    sympathetic  observa- 
tion of,  necessary,  3  1 

HOSPITAL  SOCIAL  SERVICE:   ad- 

HALL, HERBERT   J.,  M.D.,  94, 
95;    Manual  Work  in  the 
Treatment    of     Functional 
Nervous  Disease,  94 

vancing  cautiously,  203  ;  aim 
of,    i,    15,    16,    189;     and 
medical  sociology,  204-208; 
and  medicine,  202-203;  and 
the   hospital,  200-202;  and 

HANDICAPPED,  EMPLOYMENT  FOR. 

the  medical  student,   208- 

See  Medical-Social  Problems 

21  1  ;    and  the  nurse,   211- 

214;   and  the  social  worker, 

HARPER,  GRACE  L,  89,  90,  91, 

214-218;     basic    principles 

92 

of,  159,  160;    beginning  of, 

HOMEOPATHIC  HOSPITAL,  59 

6-17;      Bellevue    Hospital, 
bureau,  161;   Boston  School 

HOSPITAL:  and  private  practice, 

for  Social  Workers,   course 

difference   between,    29-31; 

in,    199;     clinics    for,    204; 

causes  of  inefficiency  in,  23, 

conservation   and   direction 

29;     community,    elements 

of    efforts    of,     164;     con- 

of, 24-28;    constricted  field 

structive,  2,  189;    contribu- 

of attention  in,  31-32;  evo- 

tion of,  to  medicine,  nursing, 

lution    of    modern,    19-22; 

and  social  work,   200;    de- 

functions   of    officers    and 

pendent    on    growth    from 

trustees,    20-21,    of   physi- 

within,   201;     development 

cians  and  nurses  in,  21,  24- 

not  a  functional  change  in 

26;    growing  popularity  of, 

hospital,  201,  202;  economic 

19;    limitations  of  time  in, 

condition  of  patients  classi- 

3 1  ;  mechanical  efficiency  of, 

fied  under,  1  29  ;  educational 

19;  necessity  for,  increasing, 
19;    organization  of,  21-22; 

value  of,  204,  205,  217,  218; 
efficiency  of,  dependent  on 

prejudice     against,     dimin- 
ishing,  19-20;    prison  and, 
conditions  in  England  and 

several  factors,  4,  102,  107; 
essential    part    of    hospital 
activity,     159,     160;     four 

France,     18;     remedy    for 

important  contributions  to, 

inefficiency    in,    29;    social 
clinic    material    in,    28-29; 

7-15;      fundamental     prin- 
ciples of,  3,  4;    future  of, 

-    social  responsibility  of,  22, 
28-29;  special  activities  of, 
should   not   be   multiplied, 
127;    technical  efficiency  of 
modern,     21-23;      ultimate 
test  of  usefulness  of,  22 

200-218;  head  worker,  com- 
petency of,  161;  high  stand- 
ard of,  required,   161;    hu- 
manity of  hospital  extended 
by,  203;  in  Buffalo  General 
Hospital,    161;     in    United 

States,  3,  15;    influence  of, 

HOSPITAL    BACKGROUND,    THE, 

beyond  institution,  200;  in- 

18-32 

itial     experiment,     159,    in 

247 


INDEX 


V 


dispensary,  15,  in  Massa- 
chusetts General  Hospital 
supported  by  private  funds, 
159;  interest  of  hospitals 
in,  22-23,  28,  29;  interpre- 
tation of,  to  hospital  authori- 
ties, 163-164;  investigator 
on  staff  at  Boston  Dis- 
pensary, 205 ;  justification 
of,  dependent  on  efficiency, 
106;  loan  funds,  86-87; 
maturity  of  hospital  ex- 
perience expressed  by,  201; 
medical-social  survey  im- 
portant before  establish- 
ment of,  176-178;  medical 
work  rounded  out  by,  202; 
methods,  embodiment  of,  in 
medical  technique,  202;  new 
profession,  203;  New  York 
School  of  Philanthropy, 
course  in,  199;  opportunity 
of,  in  hospitals  affiliated 
with  medical  schools,  210; 
originality  and  initiative 
needed  in,  190;  outcome  of 
awakened  social  conscience, 
200;  prevention  under,  204- 
205;  relief  funds,  80,  84,  86- 
87;  research  under,  208; 
social  service  students  as- 
signed to,  198-199;  special 
course  needed  for,  191-192; 
specialism  in,  140-141;  sub- 
division of  work  under, 
174-176;  superstructure  on 
medical  work,  183;  super- 
vision of,  161-164 


HOSPITAL      SOCIAL     WORKER: 
,         accurate  diagnosis  and  in- 
y  telligent    prescription    test 

of,  126,  127;    activities  of, 
stimulating    and    co-opera- 
tive,   180-182;     advantage 
.       of,  112;    aim  of,  186;    aim 
V       of    investigation    by,    123; 
attitude  of,  toward  physi- 
cian,    183-184;     avoidance 
of    "institutionalism"    by, 

248 


185;  choice  of,  important, 
1 80,  199;  confidence  of 
patient  in,  107-108;  con- 
structive work  of,  dependent 
on  co-operation  of  patient, 
109;  co-ordination  of  forces 
by,  1 86;  discharge  slips 
signed  by,  170;  divinity 
students  as,  72;  education 
of  the  neurasthenic  by,  68- 
70;  efficiency  of,  dependent 
on  several  factors,  107; 
feeble-minded  receiving 
special  attention  of,  65; 
fitness  of  trained  nurse  for, 
187-100;  friendly  criticism 
helpful,  138;  function  of, 
at  admission  desk,  164-171; 
function  of,  in  problems  of 
defective  children,  77,  of 
employment  for  handi- 
capped, 87,  of  feeble-minded, 
65,  75,  77,  of  neurasthenic, 
65,  68-72,  of  relief  work,  80, 
82-87,  of  tuberculosis,  35- 
42,  of  unmarried  mothers, 
50-60,  of  would-be  suicides, 
73;  function  of,  in  securing 
proper  convalescence,  42- 
45,  not  distinctly  medical, 
16-17,  special,  for  insane, 
65-66,  an  understanding  of 
social  and  psychic  factors, 
106-107,  111-112;  head, 
161;  home  visiting  by, 
essential,  116-^117;  imag- 
ination a  requisite  of,  130; 
in  the  clinics,  170-171; 
indiscriminate  use  of  in- 
stitutions by,  46;  insane 
receiving  special  attention 
of,  65-66;  interpreter  and 
instructor,  104-105;  in- 
terpreter between  social 
agency  and  hospital,  96- 
97,  102;  interpreter  of 
community,  184,  of  hospital, 
184-185,  of  patients,  185- 
186;  investigation  by,  as  / 
related  to  patient's  treat-  * 


INDEX 


/ment,  107-123;  investiga- 
tion by,  local  or  systematic, 
1 20-1 2 1 ;  judgment  of,  must 
be  balanced  and  sane,  121- 
122;  kindness  of,  only  one 
aspect,  1 80;  knowledge  of 
community's  resources  re- 
quisite of,  186;  lack  of 
medical  knowledge  handi- 
cap to,  190-191;  lack  of 
trained,  192;  medical  course 
for,  191;  medical  students 
as,  72;  mentally  unbal- 
anced receiving  special  at- 
/tention  of,  65;  motives  of 
investigation  by,  115-116; 
need  for,  34;  opportunity 
for  research  by,  34,  51; 
opportunity  of,  in  study  of 
causes  of  illegitimacy,  51, 
to  give  physician  important 
social  facts,  158;  outside 
social  workers,  214,  215; 
pioneer,  difficulties  of,  183; 
plastic  organizing  faculty 
requisite  of,  186-187;  pre- 
vention by  education  the 
work  of,  205,  208;  profession 
of,  not  medical,  191;  psy- 
choneurotics  receiving 

special  attention  of,  65; 
qualifications  of,  180,  181, 

182,  183,   184,   185;    quali- 
fications of  group,   182,  of 
head,  181,  182,  of  pioneer, 

183,  of  single,  182;   reading 
helpful  to,  185;   relief  work 
of,    81,    84,    85;     resource- 
fulness   requisite    of,     130; 
skill  of,  of  prime  importance, 

^  107;  social  diagnosis  by,  34; 
special,  for  psychoneurotics, 
68-72;  specialist,  140-141; 
specialization  of  functions 
of ,  1 74- 1 76 ;  standards  lack- 
ing because  of  untrained, 
192;  starting  point  for,  186; 
success  of,  192;  syphilitic 
problems  confront,  60-6 1; 
team  work  with  nurse,  182- 


183;  untrained,  192.  See 
also  Nurses;  Volunteer  Work- 
ers; Workers,  Religious 

HOWARD,  JOHN,  18 

HUMAN  BEINGS:   likenesses  and 
variations  of,  31 


ILLEGITIMATE  CHILDREN,  55-56. 
See  also  Medical-Social 
Problems,  Unmarried  Moth- 
ers 

ILLEGITIMATE  FATHER,  50,  55. 
See  also  Medical-Social  Prob- 
lems, Unmarried  Mothers 

INCAPACITATED.  See  Medical- 
Social  Problems,  Handi- 
capped 

INDIANA  SCHOOL  OF  MEDICINE, 

2O9,  2IO 

INDIANA  UNIVERSITY,  209 

INDIANAPOLIS.      See      Indiana 
School  of  Medicine 

INDIGENT:  institutional  care 
provided  for,  46 

INDIVIDUALITY.  See  Hospital 
Patients 

INDUSTRIAL  DISEASES.  See 
Medical-Social  Problems, 
Occupational  Diseases 

INSANE:  after  care  of,  in  Eng- 
land, 7,  8,  in  New  York,  8, 
in  United  States,  65;  in- 
stitutional care  for,  46 

INSTITUTIONAL  CARE:  for  chron- 
ically ill,  feeble-minded,  in- 
digent, insane,  tuberculous, 
46;  effective  medical-social 
treatment  sometimes  re- 
quires, 47;  feeble-minded 
unmarried  mother  best  pro- 
tected by,  53;  importance 
of,  46-47;  indiscriminate 
use  of,  46,  48 


249 


INDEX 


INTERDEPENDENCE  :  of  individual 
and  community  health,  217; 
of  material  and  physical 
state  of  patients,  96 

INTERDEPENDENCE  OF  MEDICAL 
AND  SOCIAL  WORK,  1-4,  13, 
16-17,  23-24,  27-30,  34, 
183,  210;  in  basis  of  treat- 
ment, 107,  110-115;  m 
constructive  plan  of  better- 
ment, 215-216;  in  feeble- 
minded infectious  patient, 
75-76;  in  feeble-minded  or 
defective  children,  77;  in 
mentally  unbalanced,  65-66; 
in  neurasthenic  cases,  68- 
72;  in  study  of  alcoholism, 
102;  in  study  of  venereal 
diseases,  102;  in  care  of 
suicidal,  73;  in  syphilitic 
cases,  64;  in  tuberculosis 
cases,  35,  36,  37,  38,  40,  41 

INTERNE.  See  Hospital,  Func- 
tions of  Physicians  and 
Nurses 

INTRODUCTION,  1-5 


JAMES,  WILLIAM:  The  Principles 
of  Psychology,  30 

JOHNS  HOPKINS  UNIVERSITY: 
social  training  of  medical 
students  in,  7,  13,  14,  15 

JORDAN,  Miss,  58 

JUVENILE  COURT:  physical  and 
mental  examination  before 
sentence  in,  96 


KING'S  CHAPEL.  See  Medkal- 
Social  Problems,  Handi- 
capped 

KING'S  DAUGHTERS,  134 


LADY  ALMONERS.    See  England 

LAKESIDE  HOSPITAL,  Cleveland, 
Ohio,  87,  156 

LEE,  DR.  ROGER  I.,  152 

LOCH,  C.  S.:  reorganization  of 
work  of  lady  almoners  by, 
8,  9,  10 

LONDON.  See  Booth's  "Life  and 
Labor  of  the  People  of  Lon- 
don" 

LONDON  CHARITY  ORGANIZATION 
SOCIETY.  See  England, 
Lady  Almoners  in  London 
Hospitals 

LONDON  HOSPITALS.  See  Eng- 
land, Lady  Almoners  in 
London  Hospitals 


MARBLEHEAD.  See  Hall,  Her- 
bert J.,M.D. 

MASSACHUSETTS  BABY  HOSPITAL, 
57,  58 

MASSACHUSETTS  CHARITABLE 
EYE  AND  EAR  INFIRMARY: 
study  of  ophthalmia  neona- 
torum,  205 

MASSACHUSETTS  GENERAL  HOS- 
PITAL: affiliation  with  King's 
Chapel  Committee  on 
the  Handicapped,  89;  card 
catalogue  of  "  resources 
of  suburban  towns,"  132; 
initial  social  service  depart- 
ment of,  supported  by  pri- 
vate funds,  159;  medical- 
social  survey  at,  176,  177, 
178;  neurological  clinic  an- 
nual report,  68,  69;  occupa- 
tional diseases  studied  at, 
207;  organization  of  social 
service  department  at,  159, 
160,  161,  162;  School  for 


250 


INDEX 


Social  Workers,  practical 
course  in,  199;  senior,  nurses 
given  experience  in  social 
service  department  of,  214; 
social  work  for  psychoneu- 
rotics  at,  68,  69,  70,  71,  72; 
study  of  debilitation  at,  152, 
204,  205;  study  of  rachitis 
and  gonorrheal  vaginitis  at, 
151.  See  also  Boston  Chil- 
dren's Hospital 

MEDICAL  ADVICE  TO  SOCIAL 
AGENT.  See  Medical-Social 
Problems 

MEDICAL  AND  SOCIAL  WORK. 
See  Co-operation;  Interde- 
pendence 

MEDICAL  CHARITIES:  checking 
abuse  of,  9,  10 

MEDICAL  SERVICE:  reforms  in, 
18,  19;  two  standards  of, 
29,  30,  3i 

MEDICAL-SOCIAL  PROBLEMS: 

Alcoholism,  33,  102;  hope- 
lessness about  confirmed, 
115;  no  special  provision 
for,  in  social  service  work, 
175;  successful  treatment  of , 
dependent  on  qualifications 
of  workers  and  more  men 
workers,  102 

Chronic  disease  victims,  33, 
46-49;  friendly  attentions 
needed  by,  48-49;  home 
care  for,  46;  institutional 
care  for,  46-49;  work  as  a 
preventive  measure  for,  95 

Convalescent  cases,  33,  42-45; 
hospital  social  worker's  ex- 
perience valuable  for,  45; 
necessity  for,  ward,  42-43 

Convalescent  home:  cottage 
plan  of,  for  children,  45; 
debilitated  patients  sent  to, 
43-44;  debility  problem  not 
solved  by,  44;  irresponsible 
life  in,  demoralizing,  43; 


limitation  of,  in  solving 
problems,  43-44;  purpose 
of,  educative,  44;  ward 
patients  in,  45 

Drug  victims,  33,  115 

Feeble-minded,  33,  75-79; 
education  concerning,  77- 
78;  high-grade,  a  social 
problem,  77;  institutional 
care  for,  46,  53,  77;  neglect 
of,  burden  on  society,  79; 
physical  defects  sometimes 
responsible  for,  77;  receiv- 
ing special  attention,  65 

Handicapped:  employment  for, 
33)  87-96;  increase  of,  in 
hospitals,  88;  industrial 
training  of,  88;  King's 
Chapel  Committee  on,  89- 
92;  re-education  of,  in 
application,  92;  survey  of 
problem,  89 

Medical  advice  to  social  agents, 
96-102 

Mentally  unbalanced,  7,  8,  33, 
46,  65-68 

Methods  of  meeting:  diverse, 

Neurasthenic,  33,  68-72;  dif- 
ference between,  and  normal 
persons,  69;  investigation 
and  education  of  the,  68-70, 
72;  social  work  for  the, 
68-72 

Neurology,  65 

Neurotic :  work  as  a  therapeutic 
measure  for  the,  94,  95 

Occupational  diseases,  152, 
157-158,  206-208 

Of  special  hospitals,  33-34 

Psychiatry,  65 

Psychoneurology,  65 

Psychoneurotic  women:  social 
work  for,  68-72 

Relief,  80-87 

Suicidal,  33,  73~7S;  cases  of» 
cared  for  at  Bellevue  Hos- 
pital, 73 ;  extent  of,  73 ; 
social  and  psychological  as- 
pects of,  73 


251 


INDEX 


Syphilis,  33,  60^64;  attitude 
of  relief  agencies  toward,  60; 
hospital  facilities  for  care 
of,  lacking,  60;  hospital 
social  workers  confronted 
by,  60,  61;  prevention  of, 
by  education,  64;  problem 
of,  moral,  physical,  and 
social,  64;  stigma  attached 
to,  60;  team  work  in  cases, 
61,  62,  63,  64;  treatment 
essential  for,  64;  venereal 
origin  of,  64 

Tuberculosis:  movement 
against,  40-42;  prevention 
of,  through  education,  41- 
42;  social  conscience  aroused 
by,  42 

Tuberculous,  33,  35-42;  after- 
care of,  40;  expense  of 
caring  for,  41;  institutional 
care  for,  46;  patient  re- 
fusing hospital  care,  41; 
problem  of,  among  immi- 
grants, 39,  distinctly  social, 
35,  unsolved,  41;  segrega- 
tion of,  40;  social  worker 
important  element  in  treat- 
,-  ment,  37-38 
„  Uniformity  in,  33 

Unmarried  mothers,  33,  50- 
60;  Boston  Dispensary  plan 
for,  56-57;  children's  aid 
societies  deal  with  children 
of,  56;  complete  protection 
of  irresponsible,  important, 
53;  constructive  work  with, 
50-56;  emotional  religious 
experience  unwholesome  for, 
53~54>  illegitimate  child 
greater  problem  than  mother, 
55;  institutional  care  un- 
sound for  normal,  53;  in- 
stitutional protection  for 
feeble-minded,  53;  inter- 
pretation of  social  laws  to, 
51;  keeping  in  touch  with, 
52;  legal  protection  of,  and 
baby,  55;  marriage  for,  55; 
mental  suffering  of,  52; 


recognition  of  forces  sur- 
rounding, 50,  51;  "rescue 
homes"  for,  54;  responsi- 
bility of  motherhood  incul- 
cated in,  54 

Venereal  diseases,  103,  104; 
cases  of,  approached  from 
medical  side,  102;  educa- 
tional work  and  investiga- 
tion of  causes  in,  103;  in- 
effective treatment  of,  103; 
successful  treatment  of,  de- 
pendent on  qualifications  of 
workers  and  more  men 
workers,  102 

MEDICAL  SOCIAL  SERVICE.  See 
Hospital  Social  Service 

MEDICAL  SOCIAL  WORKER.  See 
Hospital  Social  Worker 

MEDICAL  SOCIOLOGY.  See  Hos- 
pital Social  Service  and 
Medical  Sociology 

MEDICAL  STUDENTS:  opportun- 
ity of  socially-minded,  210; 
social  training  of,  7,  13- 
15,  208-211;  volunteer 
service  of,  in  social  service 
department,  198.  See  also 
Hospital  Social  Service  and 
the  Medical  Student 

MEDICAL  WORKERS:  develop- 
ment of  social  conscience 
in,  23,  28,  29;  socially- 
minded,  208,  209.  See  also 
Hospital  Social  Service 

MEDICO-SOCIAL  SURVEYS,  176- 
179;  at  children's  clinic, 
Massachusetts  General  Hos- 
pital, 177-178;  at  eye  clinic 
of  Boston  Dispensary,  176- 
177;  at  mental  clinic  of 
Boston  Dispensary,  177; 
importance  of,  before  estab- 
lishment of  hospital  social 
service,  176-178;  of  cases  of 


252 


INDEX 


debilitation  at  Massachu- 
setts General  Hospital,  152, 
204,  205 ;  of  cases  of  gonor- 
rhea at  Boston  Dispensary, 
103;  of  hospital  patients, 
128,  129;  show  needs  of 
dispensary  treatment,  178; 
test  of  efficiency,  178,  179 

MENTAL  DEFECTIVES.  See 
Medical-Social  Problems, 
Feeble-minded 

MENTALLY  DEFECTIVE  CHIL- 
DREN :  physical  defects  some- 
times responsible  for,  77. 
See  also  Medical-Social 
Problems,  Feeble-minded 

MENTALLY    UNBALANCED.    See 

Medical-Social  Problems 

MONTEFIORE,  COLONEL,  9,  IO 

MORROW,  DR.  PRINCE  A.,  208 


NATIONAL  ASSOCIATION  FOR 
MENTAL  HYGIENE:  after- 
care of  insane,  65 

NEURASTHENICS.  See  Medical- 
Social  Problems 

NEUROLOGY.  See  Medical- 
Social  Problems 

NEW  YORK: 

After-care  of  the  insane,  8 
Charity  Organization  Society, 
2;    Bureau   for  the  Handi- 


School  of  Philanthropy: 
hospital  social  service  course 
at,  199;  nurses  as  pupils  in, 
212 

Social  service  students  as- 
signed to  hospital  work  in, 
198-199 

State  Charities  Aid  Associa- 
tion: after-care  of  insane, 
65 


Teachers  College:  course  in 
public  health  nursing  at, 
212.  See  also  Bellevue 
Hospital;  Presbyterian  Hos- 
pital 

NIGHTINGALE,    FLORENCE,    19, 

217 

NURSE:  hospital  social  service 
and  the,  211-214 

NURSES:  as  pupils  in  schools  for 
social  workers,  212;  dis- 
tribution of  material  relief 
by,  81;  effect  of  hospital 
social  service  on  training 
of,  211-214;  fitness  of 
trained,  for  hospital  social 
service,  187-190;  function 
of,  in  hospitals,  21,  24-26; 
public  health,  work  for,  211- 
212;  senior,  given  experi- 
ence in  social  service  depart- 
ment, 214;  socially  trained, 
211-214;  training  of,  25- 
26;  training  the  special, 
211-214 

NURSING:  course  in  public 
health,  at  Teachers  College, 
212;  differences  between , 
and  social  work,  188-189; 
history  of,  19;  reforms  in, 
19;  religious  orders,  6-7; 
schools  for  visiting  nursing, 
212;  visiting,  6,  7,  n,  13, 
212,  213;  visiting,  in  con- 
nection with  Presbyterian 
Hospital  in  New  York,  12, 
13,  213;  visiting,  in  United 
States,  8 1 

NUTTING,  M.  ADELAIDE,  AND 
DOCK,  LAVINIA  L.:  A 
History  of  Nursing,  19 


OCCUPATIONAL    DISEASES.    See 
Medical-Social  Problems 

OPHTHALMIA  NEONATORUM:  spe- 
cial study  of,  205 


253 


INDEX 


ORGANIZATION  OF  SOCIAL  SER- 
VICE DEPARTMENT,  159-179; 
axiomatic  principles  of,  161; 
best  form  of,  160,  161;  ex- 
isting forms  of,  1 60,  161; 
integral  part  of  hospital, 
178,  179,  1 86;  present  di- 
versity of,  160;  supervision 
by  advisory  committee,  162, 
163,  164;  supervision  by 
social  service  committee,  162 

OUT-PATIENT  WORK:  efficiency 
of,  103,  130.  See  also  Hos- 
pital Social  Service 


PATIENTS.    See  Hospital  Patients 

PELTON,  GARNET  I.:  pioneer 
hospital  social  worker,  16 

PENNSYLVANIA.  See  University 
of  Pennsylvania  Hospital 

PHILADELPHIA  CHILDREN'S  AID 
SOCIETY:  illegitimate  chil- 
dren cared  for  by,  56 

PHYSICAL  BETTERMENT:  effect 
of,  on  character,  216-217 

PHYSICIANS.  See  Hospital 
Functions  of  Physicians; 
Hospital  Social  Service  and 
the  Medical  Student;  Medical 
Workers 

PREGNANT  GIRLS.  See  Medical- 
Social  Problems,  Unmarried 
Mothers 

PRESBYTERIAN  HOSPITAL,  NEW 
YORK:  visiting  nursing  in 
connection  with,  12-13,  213 

PREVENTION.  See  Hospital 
Social  Service  and  Medical 
Sociology 

PROBLEMS.  See  Medical-Social 
Problems 


PSYCHIATRY.  See  Medical- 
Social  Problems 

PSYCHOLOGICAL  ELEMENTS  : 
fundamental  importance  of, 
in,  112,  123 

"PSYCHOLOGY,  PRINCIPLES  or," 
by  William  James,  30 

PSYCHONEUROLOGY.  See  Medi- 
cal-Socivl  Problems 

PSYCHONEUROTIC.  See  Medical- 
Social  Problems 

PSYCHOPATHIC  WARD,  Belle vue 
Hospital,  65 

PUBLIC  HEALTH:  through  edu- 
cation, 217,  218.  See  also 
Nurses;  Nursing 

PUTNAM,  DR.  JAMES  J.,  68,  69 


RACHITIS:  medical-social  study 
of,  151 

RECORDED  CASES:  treatment  of, 
more  intelligent,  144 

RECORDED  STATISTICS:  co-opera- 
tion with  other  agencies 
shown  by,  154;  lack  of 
educational  facilities  for 
crippled  children  shown  by, 
155;  need  of  limitation  of 
work  or  of  additional  work- 
ers shown  by,  144-145,153- 
154;  use  of,  for  medical- 
social  studies,  153;  useful- 
ness and  policies  of  depart- 
ment shown  by,  154;  value 
of,  as  basis  for  special  efforts, 
155;  value  of,  for  compara- 
tive purposes,  154,  155 

RECORDS,  142-158;  analytic,  for 
occupational  diseases,  158; 
Boston  Children's  Hospital 
medical-social,  158;  case, 
show  important  social  facts, 


254 


INDEX 


158;  confidential  nature  of, 
145;  cross  referencing  medi- 
cal and  social,  156-157; 
development  of  medical- 
social,  marks  recognition  of 
social  service,  158;  distinc- 
tion between  facts  and  im- 
pressions in,  148;  essential 
facts  in,  149-150;  family 
unit  the  basis  of,  146;  im- 
portance of,  142;  individual, 
the  basis  of,  146;  knowledge 
of  good  technique  secured 
from,  148;  Lakeside  Hos- 
pital medical-social,  156- 
157;  length  of,  148;  medi- 
cal, 142;  medical  record 
supplemented  by  social  facts, 
157-158;  medical-social  sur- 
vey shows  need  of  better, 
178;  method  of  preparing, 
147;  notation  on  medical, 
of  social  activities,  156; 
occasional  summary  of  ac- 
complishment in,  147;  re- 
lation of  disease  to  occupa- 
tion shown  by,  152,  157; 
separation  of  medical  and 
social,  155-156;  statistical 
and  narrative,  145-147, 149- 
150;  systematizing,  144; 
type  of  suitable  social,  143- 
147;  uniformity  in,  for 
medical-social  study,  150- 
151;  use  of  case,  142,  144, 
146,  147,  158;  use  of,  for 
social  welfare  justifiable, 
145,  for  statistical  inquiries, 
151-154,  for  study  of  gon- 
orrheal  vaginitis,  151,  for 
study  of  occupational  dis- 
eases, 152,  for  study  of 
rachitis,  151 

REGISTRATION       DEPARTMENT. 
See  Selection  of  Cases. 

RELIEF.        See    Medical-Social 
Problems 

"RESCUE  HOMES,"  54 


RICHARDS,  ELIZABETH  V.  H., 
viii 

RICHMOND,  MARY  E.,  viii 

ROYAL  FREE  HOSPITAL,  London. 
See  England,  Lady  Almoners 
in  London  Hospitals 


ST.  Louis:  social  service  stu- 
dents assigned  to  hospital 
work  in,  198-199;  nurses 
as  pupils  in  school  of 
philanthropy  in,  212.  See 
also  Washington  University 
Hospital 

ST.  Louis  CHILDREN'S  HOSPITAL: 
organization  of  social  service 
department,  163 

ST.  MARY'S,  59 

ST.  VINCENT  DE  PAUL  SOCIETY, 
18,  134;  Sisters  of  Charity 
under,  18 

SALVATION  ARMY  HOME,  58 
SCABIES,  104 

SELECTION  OF  CASES,  164-174; 
adequate  plan  for,  171-173; 
admission  desk  strategic 
point  for,  164-171;  by 
physician  and  hospital  social 
worker,  171;  by  physicians 
in  clinics,  169;  case  work 
type  in,  174;  clinical  type 
in,  174;  for  free  clinic,  165- 
166;  in  dispensaries,  165; 
in  out-patient  departments, 
165;  in  wards,  164-165; 
medical-social  diagnosis  for, 
169-170;  patients  to  be 
discharged  interviewed  in, 
165;  recommendation  of 
medical  workers  in,  165; 
types  governing,  171-174 

SEX:  problems  of,  least  under- 
stood, 50 


255 


INDEX 


: 


SISTERS  OF  CHARITY.  See  St. 
Vincent  de  Paid 

SMITH,  RICHARD  M.,  M.D.: 
Vulvovaginitis  in  Children, 
104 

SOCIAL  AGENCIES:  co-operation 
of  hospital  social  worker 
with,  125-126,134;  organi- 
zation of,  in  communities, 
124-125;  patient  sent  by, 
for  physical  examination, 
06-08;  private,  132-134; 
public,  132-134;  similarity 
of  problems  of  medical  and 
other,  128.  See  also  Com- 
munity's Resources;  Confi- 
dential Exchange 

SOCIAL  AGENTS:  medical  advice 
to.  See  Medical  -  Social 
Problems;  Medical  Advice  to 
Social  Agents 

SOCIAL  AND  MEDICAL  WORK. 
See  Co-operation;  Interde- 
pendence 

SOCIAL  ASPECTS  OF  A  MEDICAL 
INSTITUTION,  171 

SOCIAL  CONFERENCE:  weekly, 
in  medical  clinic  of  Indiana 
School  of  Medicine,  200- 
210 

SOCIAL  DIAGNOSIS:  supplemen- 
tary to  medical,  203 

SOCIAL  DISTRESS:  disease  cause 
and  result  of,  2,  23,  27-29, 
215,  216 

SOCIAL  PROBLEMS.  See  Medi- 
cal Social  Problems 

SOCIAL  PROGRESS:  lessening  of 
disease  important  for,  2 

SOCIAL  SERVICE:  constructive, 
dependent  on  physical  con- 
dition, 215-216;  emergency, 
119-120;  specialism  in,  140- 
141,  174-176 


SOCIAL  TRAINING.  See  Medical 
Students;  Nurses,  Socially 
Trained 

SOCIAL  WORKER.  See  Hospital 
Social  Worker 

SOCIETY  FOR  AFTER  CARE  OF 
POOR  PERSONS  Discharged 
Recovered  from  Insane  Asy- 
lums. See  England,  Society 
for  After  Care  of  Insane 

SOCIETY  FOR  PREVENTION  OF 
CRUELTY  TO  CHILDREN,  60 

SOCIOLOGICAL  AND  PHYSICAL 
SUFFERING.  See  Disease 

SOUTH  BOSTON  ASSOCIATED 
CHARITIES,  58 

SPECIALISM.    See  Social  Service 
STATE  BOARD  OF  CHARITY,  60 

STATE  CHARITIES  AID  ASSOCIA- 
TION, New  York.  See  New 
York,  After  Care  of  the  In- 
sane 

STATE  INFIRMARY,  58,  59 

STATISTICS.  See  Recorded  Sta- 
tistics 

STEFFENS,  LINCOLN,  1 14 

SUBDIVISION  OF  SOCIAL  WORK  IN 
HOSPITALS,  174-176 

SUICIDAL.  See  Medical-Social 
Problems ,  Suicidal 

SUPERVISION,  161-164;  of  vol- 
unteer worker  by  paid 
worker,  193,  196-197 


See  Medico-Social 


SURVEYS. 
Surveys 

SYPHILITICS.       See  Medical-So- 
cial Problems 


256 


INDEX 


TABLES:  classification  of  eco- 
nomic condition  of  116  pa- 
tients applying  at  Boston 
Dispensary,  129 

TEACHERS  COLLEGE.  See  New 
York,  Teachers  College 

THOMPSON,  DR.  W.  OILMAN,  158; 
Classification  of  Occupa- 
tional Diseases,  206 

TREATMENT:  basis  of,  106-123; 
constructive,  dependent  on 
physical  condition,  215-216; 
definiteness  in,  123;  ef- 
fective medical-social,  de- 
pendent on  social  investiga- 
<^/  tion,  114;  final  plan  of, 
composite,  117;  importance 
of  psychological  elements 
in,  IH-II2,  122-123;  pa- 
tient's plan  of,  117;  results 
prove  value  of  plan  of,  114- 
115;  second  best  plan  of, 
in;  social  facts  modifying, 

IIO-II2,  II4-II6,  IIQ,  120- 

123;  sound  plan  of,  de- 
pendent on  true  facts,  123; 
tentative  social  plan  of, 
110-120 

TUBERCULOUS.  See  Medical- 
Social  Problems 


UNION  HOSPITAL  OF  FALL  RIVER  : 
family  unit  basis  of  record 
at,  146 

UNITED  STATES:  after-care  of 
insane  in,  65;  hospital 
social  service  in,  3,  15; 
investigation  of  occupational 
diseases  in,  206;  visiting 
nursing  in,  81 

UNIVERSITY  OF  PENNSYLVANIA 
HOSPITAL:  volunteer  work- 
ers at,  194 

UNMARRIED  MOTHERS.  See 
Medical-Social  Problems 


VENEREAL  DISEASES.  See  Medi- 
cal-Social Problems 

VOLUNTEER  WORKERS,  6-7, 192- 
199;  and  patients  in  institu- 
tions, 48-49;  at  Belle vue 
Hospital,  194;  at  University 
of  Pennsylvania  Hospital, 
194;  book  of  instructions 
and  information  for,  197; 
care  in  selecting,  194-195; 
limiting  number  of,  194; 
professional  social  workers 
recruited  from,  194; 
promptness  and  regularity 
of,  195;  reports  of,  on  out- 
side work,  196;  responsi- 
bility of,  195;  seeking, 
among  students  and  the 
professions,  197-198;  ser- 
vice of,  not  new,  192; 
statistical  or  clerical  work 
for,  195;  supervision  of,  by 
paid  worker,  192,  193,  196, 
197;  value  of  trained,  194; 
visiting,  195;  weakness  of 
independent  work  by,  193; 
weekly  conference  between, 
and  paid  worker,  197 

VULVO-VAGINITIS,  103-104 

WARNER,  DR.  See  Lakeside 
Hospital 

<  WASHINGTON  UNIVERSITY  HOS- 
PITAL AT  ST.  Louis,  155 

|  WATERS,  YSSABELLA:  Visiting 
Nursing  in  the  United  States, 
81 

WORCESTER  MEMORIAL  HOS- 
PITAL: selection  of  patients 
requiring  social  care,  165 

I  WORKERS,  180-199;  religious, 
6,  7.  See  also  Hospital 
Social  Workers;  Volunteer 
Workers 

WORKING  TOGETHER,  124-141. 
See  also  Co-operation;  In- 
terdependence 


257 


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A    000019556    o 


